8/9/2013 � No financial disclosures Management of Atrial Fibrillation in 2013 Katherine Julian, MD August 9, 2013 Epidemiology Why Is This Important? � Most common arrhythmia in clinical practice � AF associated with an increased risk of stroke � 2.3 million people in North America � Six-fold increase in rate of ischemic stroke � Average cost of $3600/patient/year � Rate of ischemic stroke in non-valvular AF approx 5%/year � Accounts for 1/3 of all hospitalizations for cardiac rhythm disturbances � AF accounts for 15% of all strokes � Prevalence: 0.4-1% in the general population and � Associated with increased CHF and all-cause 8% in those older than 80 years mortality Singer DE, et al. Chest, 2004;126. 1
8/9/2013 Atrial Fibrillation Case I � Work-Up � 55 yo woman being seen for a new patient visit. Asymptomatic. � Rate vs. Rhythm Control � PMH: HTN (untreated) � Treatment Options � PE: 150/80, HR 125 Irregularly irregular � Anti-coagulation � Future Treatment Options The EKG… What Work-Up Does She Need? � Complete history and physical � PIRATES 2
8/9/2013 Secondary Causes of AF Secondary Causes of AF � PIRATES – secondary causes � Other Secondary Causes � Pericarditis � Obesity – likely due to LA dilatation � Pulmonary disease/pulmonary embolism � ?Smoking � Ischemia � Familial � Rheumatic heart disease � ?Inflammation � Atrial myxoma � Treat Underlying Etiology � Thyrotoxicosis � Ethanol � Sepsis What Work-Up Does She Need? What Work-Up Does She Need? � ECHO � Complete history and physical exam � Rheumatic heart disease � Pulmonary disease/pulmonary embolism � Atrial myxoma � Ischemia � The real reason… � Ethanol � LVH � Sepsis � Occult valvular disease � Occult pericardial disease Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 3
8/9/2013 What Work-Up Does She Need? Classification � Recurrent: 2 or more episodes � Complete history and physical exam � Paroxysmal: arrhythmia terminates spontaneously � TTE � Persistent: sustained beyond 7 days and is not self- � EKG terminating � CXR � Permanent: cardioversion has failed (or been foregone) � Associated labs � Lone: patients <60 years without clinical/EKG � TSH, (CBC, renal and hepatic function) evidence of cardiopulmonary disease (incl htn) � Other tests based on history…ex: event monitor Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 Case I What is the Next Step for Our Case? � 55 yo woman being seen for a new patient visit. What should be our goal in treatment? Asymptomatic. 1. Convert her to sinus rhythm � PMH: HTN (untreated) 68% 2. Rate-control � PE: 150/80, HR 125 Irregularly irregular 3. Stroke prevention 4. #1 and #3 21% 5. #2 and #3 6% 3% 3% Convert her to... Rate-control Stroke prevent... #1 and #3 #2 and #3 4
8/9/2013 Hemodynamic Consequences of Rate or Rhythm? AF � Loss of atrial mechanical function - fibrosis � AFFIRM Study � Irregular ventricular response � Randomized 4070 patients with AF, F/U 3.5 years � Rate-control = coumadin � Elevated HR � Rhythm-control = cardioversion/meds/coumadin � Results in: � No difference in survival, stroke or QOL � Reduction in diastolic filling, stoke volume, CO � Trend towards increased survival in rate-control (P = .08) � Risk of cardiomyopathy (chronic > 130 bpm) � Pts > 65 yrs and pts without h/o CHF had better outcomes with rate-control therapy � Asymptomatic afib 12X more common… � More thrombotic events in rhythm arm AFFIRM Investigators, NEJM, 2002;347 Rate or Rhythm? Rate or Rhythm for CHF Patients � 1376 patients with h/o afib, EF<35%, sx of CHF � AFFIRM Study…the Caveats… � RCT rate vs. rhythm � No symptomatic patients � Outcome: time to death from CV causes, followed 37 � Average age of enrollees: 70 yrs months � Only 63% of patients in control arm in sinus rhythm � Results � 27% in rhythm-control group died from CV causes � 25% in rate-control group died from CV causes � HR 1.06 � Other outcomes similar (CVA, worse CHF, all-cause mortality) AFFIRM Investigators, NEJM, 2002;347 Roy, et al. NEJM, 2008;358. 5
8/9/2013 Rate Control Rate Control � Previous goal HR: 60-80 bpm at rest; 90-115 � What do I use? bpm during exercise � First choice: beta-blockers or calcium-channel blockers � No evidence getting � Don’t give if Wolf-Parkinson-White or other accessory HR <80 vs. <110 any pathways better for mortality � OK to combine nodal-blocking agents � Digoxin is second-line as it does not control HR � No benefit during exercise to strict control (if no sx and EF>40%) Van Gelder IC et al. NEJM 2010;362 Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 Groenveld HF, et al. J Am Coll Cardiol 2013 What About Rhythm vs. Rate…Bottom Line Cardioversion? � Highly symptomatic or unstable: � Electrical cardioversion preferred rhythm control � Best if within 7 days of AF onset � If minimal symptoms: rate � Requires conscious sedation or anesthesia control is safe and appropriate � Most thrombi in atrial fibrillation arise from the LA (maintain goal HR <110) appendage � Anticoagulation therapy should be � Cardioversion can reduce LA appendage function continued regardless of the strategy (rhythm vs. rate) � Peri-cardioversion period is particularly pro- thrombotic � Regardless of mode of cardioversion 6
8/9/2013 Electrial Cardioversion Cardioversion – Thrombus Risk � If AF < 48 hrs, can safely undergo cardioversion without � Other factors besides LA clot may affect stroke risk anticoagulant therapy � Age � Must be documented! � DM � If AF > 48 hrs (or unknown duration) OR high-risk for � LA flow velocity stroke (h/o stroke/TIA, mechanical heart valve), then 2 � HTN choices: � Anti-coagulate X 3 weeks (therapeutic INR) before cardioversion � One study showed intra-atrial thrombus has been � TEE to r/o clot detected by TEE in 15% of patients with AF < 72 � Anti-coagulate for at least 4 weeks afterward hours duration � Anti-coagulate also for those who would not normally require � No difference in thrombus risk between electrical and coumadin pharmacologic cardioversion Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 Pharmacologic Cardioversion – The Next Step… Stable Patients 55 yo woman being seen for a new patient visit. Asymptomatic. PMH: HTN (untreated) � Pharmacologic cardioversion in AF < 7 days PE: 150/80, HR 125 Irregularly irregular � Type 1C 59% � Flecainide � Propafenone Does she need anti-coagulation? � Type III 29% Yes, with coumadin 1. � Dofetilide Yes, with ASA 2. � Ibutilide 7% Yes, with coumadin and ASA 3. 2% 2% � Pharmacologic cardioversion in AF > 7 days Yes, with dabigatran (pradaxa) 4. � Proven efficacy: dofetilide, ibutilide, amiodarone . . A . . . . o . . . N m S m i A b a u h u No o o d 5. t c i c h w h h t i t , t w w i s w i e , , Y , s s s e e e Y Y Y Fuster et al. ACCF/AHA/HRS Practice Guidelines. J Am Coll Cardiol . 2011 7
8/9/2013 Key Point… Risk/Benefits of Coumadin � Pooled analysis from five primary prevention � A rhythm control strategy does not negate the trials in non-valvular AF need for anticoagulation therapy � Annual rate of stroke 4.3% in control group � Assuming anticoagulation is indicated � 1.4% risk of stroke in the warfarin group (NNT=32) � Only 20% of subjects >75 yrs; excluded pts at risk for bleed � Need to consider warfarin risks � Symptomatic intracranial hemorrhage 0.4% with warfarin; 0.2% in control � Major bleeding: 2.2% with warfarin; 0.9% in control Bath PMW, et al. European Heart Journal, 2005 What About Aspirin? Secondary Prevention of Stroke � Two randomized trials evaluated the use of ASA � Risk of stroke with warfarin 3.1%; placebo 10% (75mg, 325mg) in primary stroke prevention � Risk of stroke with ASA (300mg) 7.7% � Pooled data: Risk of stroke with ASA 4.2%; risk of stroke in controls 6.4% � ASA may be better in preventing non- cardioembolic strokes and non-disabling strokes EAFT Study Group, Lancet, 1993 Bath PMW, et al. European Heart Journal, 2005 8
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