Management of Atrial Fibrillation Management of Atrial Fibrillation Nitish Badhwar, MD, FACC Nitish Badhwar, MD, FACC University of California, San Francisco University of California, San Francisco Risk Appraisal Forum Risk Appraisal Forum April 23, 2010 April 23, 2010
• Incidence and Disease Burden • Drug therapy • Drug therapy • Role of Catheter ablation • Outcomes Data
Overall and sex-specific trends in age-adjusted incidence of AF between 1980 and 2000 (age adjustment to the 1990 US population) Miyasaka, Y. et al. Circulation 2006;114:119-125
Projected Prevalence of Atrial Fibrillation in United States between 2000 and 2050 United States between 2000 and 2050 Miyasaka, Y. et al. Circulation 2006;114:119-125
Incidence of Atrial Fibrillation in different age groups groups Miyasaka, Y. et al. Circulation 2006;114:119-125
Hospitalization for Arrhythmias (USA) 6% PSVT 6% 18% PVCs Unspecified 4% Atrial Flutter Atrial fibrillation accounts for 1/3 of all patient 9% 34% discharges SSS Atrial with arrhythmia as with arrhythmia as Fib ill ti Fibrillation principal diagnosis. 8% Conduction Conduction Disease 10% VT 3% SCD 2% VF Bialy D et al. JACC. 1992;19:41A
Presence of Heart Disease in Consecutive Presence of Heart Disease in Consecutive Outpatients with AF O t Outpatients with AF O t ti ti t t ith AF ith AF 35% 65% Lone AF Heart di Prystowsky et al. Circulation. 1996;94:I-191
Symptom Profile • 3 patients (2%) had non-lethal cardiac arrest • The most frequent symptoms were: palpitations (96%), dizziness (75%), and shortness of breath (47%) • 20% of subjects (33 of 167) reported at least 1 20% of subjects (33 of 167) reported at least 1 episode of syncope which was preceded by palpitations • Symptoms were significantly (p< 0.05) different in the Symptoms were significantly (p< 0 05) different in the AF/AFL group vs. other types of SVT • Despite a low incidence of associated heart disease, and good LV function, there was a high frequency of disabling, potentially life-threatening symptoms associated with episodes of SVT Wood et al., Am J Cardiol. 1997:79(2):145 Wood et al., Am J Cardiol. 1997:79(2):145- -9 9. .
Consequences of Atrial Fibrillation q • Arrhythmia- associated symptoms • LV function, exercise tolerance, and , , QOL • Tachycardia- mediated cardiomyopathy • 5- fold in stroke risk • Significant burden to healthcare system g y
Classification of Atrial Fibrillation Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE. 1992;20:1603-1605
Management of Atrial Fibrillation g Therapy goals may include: • Control of the heart rate (symptom-reduction, rate-control ) (symptom reduction, rate control ) • Restoration and maintenance of normal sinus rhythm (intervention and termination, rhythm-control ) • Reduction in thrombo-embolic complications ( risk reduction for stroke)
• Incidence and Disease Burden • Drug therapy • Drug therapy • Role of Catheter ablation • Role of Imaging
Percentage of Strokes Associated with Atrial Fib ill ti Fibrillation Wolf P, Abbott RD, Kannel WB. Arch Intern Med. 1987;147:1561-1564.
Risk of Stroke and Bleeding with Warfarin in Atrial Fibrillation At i l Fib ill ti 5 4.5 4 4 Placebo Placebo Warfarin Warfarin 3.5 3 2.5 2 5 2 1.5 1 0.5 0 Stroke Bleeding Atrial Fibrillation Investigators. Arch Intern Med. 1994;154:1449-1457.
Risk factors for Stroke in Patients with AF Risk factors for Stroke in Patients with AF • High Risk g – Previous CVA, TIA – Rheumatic mitral stenosis • Moderate Risk – Age > 75 g – HTN – DM – CHF, EF < 35% • Hyperthyroidism • HOCM AF Guidelines. 2006.
Dabigatran vs Warfarin in Atrial Fibrillation g Connolly et al. N Eng J Med. 2009;361:1139-51.
Newer Rx for Stroke Prevention Newer Rx for Stroke Prevention • Left Atrial Appendage Occluding devices – Watchman device – Place device • Drugs – Oral direct thrombin inhibitors (Dabigatran) – Direct factor X a inhibitors • Parenteral (Fondarinux) Parenteral (Fondarin ) • Oral (Razaxaban) – Odiparcil p
Pharmacological cardioversion Pharmacological cardioversion g • Ibutilide Ibutilide • Parenteral procainamide, flecainide, propafenone, sotalol f t l l • Dofetilide • Pill in the pocket (oral) – Flecainide (200 / 300 mg) – Flecainide (200 / 300 mg) – Propafenone (450 / 600 mg) – Need AV nodal blockers
Newer Drugs for Rhythm Control Newer Drugs for Rhythm Control g g y y • Dronederone Dronederone • Azimilide • Trecetilide • Atrial specific p – Tediasamil – RSD 1235 RSD 1235 – ZP 123 (gap junction enhancer) – AVE 0118
AFFIRM Atrial Fibrillation Follow-up: Investigation of Rhythm Management • Entry Criteria • Outcomes Data PAF Persistent AF PAF, Persistent AF Survival Survival – – < 65 w/ risk fx, or >65 w/o Total mortality – – 6 hr of AF QoL, cost – – Disabling stroke, hemorrhage, SCD g , g , – • Treatment Arms • Study Results Randomized, multicenter – Rhythm + anticoag N=4060; (~2030 each group) – – Rate + anticoag Mean f/u 3.5 yrs – – Rhythm control offered no survival – benefit Rhythm = AADs or CV, devices & – RFA rarely used RFA rarely used More adverse events (CVA death More adverse events (CVA, death, – Rate = ß, & Ca + channel blkrs, hospitalizations) in Rhythm arm – digoxin, 5% ablate & pace, 6MWD NEJM 2002;347:1825-1833
• Incidence and Disease Burden • Drug therapy • Drug therapy • Role of Catheter ablation • Role of Imaging
Ablation for Atrial Fibrillation • AV nodal ablation for rate control • Ablation of precipitating arrhythmia (tachycardia induced tachycardia) (tachycardia induced tachycardia) • Ablation to cure atrial fibrillation
Singer: Interventional Electrophysiology. Williams & Wilkins 1997; 328. AV Junction Ablation
Ablate (AV Junction) and Pace ( ) • Clinical improvement – Fewer symptoms – Better exercise tolerance Better exercise tolerance – Improved QOL • Improved hemodynamics – CO increased CO increased – Improved EF – Small but real incidence of post-procedure SCD • PAVE Trial PAVE T i l – Biventricular pacing post ablation improved EF – RV pacing decreased EF
Ablation for Atrial Fibrillation • AV nodal ablation for rate control • Ablation of precipitating arrhythmia (tachycardia induced tachycardia) (tachycardia induced tachycardia) • Ablation to cure atrial fibrillation
Tachycardia-Induced Tachycardia Tachycardia Induced Tachycardia • One tachycardia degenerates into another One tachycardia degenerates into another • Examples: –Atrial flutter and atrial tachycardia into AF Atrial flutter and atrial tachycardia into AF –AV node reentry into AF –AV reentry into AF • Treating the initiating tachycardia can help prevent future episodes of AF
SF UC
AVNRT AVNRT Atrial Fibrillation Atrial Fibrillation Sauer et al. Circulation 2006;114:191 Sauer et al. Circulation 2006;114:191- -195. 195.
Yang Y et al. AJC 2003;91(1):46 Yang Y et al. AJC 2003;91(1):46- -52 52
Ablation for Atrial Fibrillation • AV nodal ablation for rate control • Ablation of precipitating arrhythmia (tachycardia induced tachycardia) (tachycardia induced tachycardia) • Ablation to cure atrial fibrillation
Cut and Sew Maze Procedure Cut and Sew Maze Procedure Ad, N and Cox, JL. J Card Surg 2004;19:196 Ad, N and Cox, JL. J Card Surg 2004;19:196- -200 200
Long term efficacy of Cox Maze III Long term efficacy of Cox Maze III Prasad SM. J Thorac Cardiovasc Surg. 2003;126:1822 Prasad SM. J Thorac Cardiovasc Surg. 2003;126:1822- -28. 28.
Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation Wolf et al. Wolf et al. J Thorac Cardiovasc Surg.2005;130:797-802.
Catheter Maze (LA) procedure ( ) p • 42 patients in study, 40 treated • 36 initially successful procedures 4 failures • 36 initially successful procedures, 4 failures • 4 total deaths, all unrelated to procedure • 9 severe complications, 2 mild – 3 CVA’s – 1 hemodynamic collapse – 1 pericardial effusion / pericardiocentesis – 1 infection related 1 infection related – 1 ARDS – 1 anaphylactic reaction – 1 blood loss / transfusion – 1 blood loss / transfusion – 2 pressure sores
Focal Atrial Fibrillation Focal Atrial Fibrillation Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins Originating in the Pulmonary Veins Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Mélèze Hocini, M.D., Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D., Mélè Mélèze Hocini, M.D., Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D., Mélè H H i i M D Gill i i M D Gill Q i i Q i i M D S é h M D S é h G G i i M D Al i L M M D Al i L M M D M D Philippe Le Métayer, M.D., and Jacques Clémenty, M.D. Philippe Le Métayer, M.D., and Jacques Clémenty, M.D. 1998 1998
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