OUTLINE Case studies 1) AF on pacemaker 2) AFL on dofetilide - PDF document

9/30/2015 The more we look the more we see The more we see the less the we know… David Singh MD Cardiac Electrophysiology Queens Medical Center OUTLINE  Case studies  1) AF on pacemaker  2) AFL on dofetilide patient  3) Post ablation patient  BACKGROUND AF  Description change in monitoring  Mobile telemetry  Patches  ILR  AF burden and stroke ‐ review trials  Are symptomatic AF and asymptomatic AF different  ASSERT TRENDS   Montoring AF post ablation/aa drug therapy  Case illustrating post ablation  Cryptogenic stroke 1

9/30/2015 Case 1  78 year old female s/p AFIB ablation X 2 at UCSF  Despite ablation continued to have frequent AF and feels terrible when she is in it.  Started on Dofetilide and cardioverted  Since then has been feeling great subjectively no AF  Has a history of HTN  CHADS Vasc of 3  Since she feels she has no Afib she would like to get off of OAC Next Steps?  1) Tough luck: you are stuck with OAC  2) Sounds great! Lets stop your OAC  3) Perform monitoring to determine AF burden and make decision based on results. 2

9/30/2015  LINQ VIDEO 3

9/30/2015 Case 2  84 year old with history of AFL s/p Ablation  EF 25%  Was on coumadin but stopped because of mild GI bleed  CHADS VASC of 4  SSS s/p SCPM Interrogation in office 10/2014 4

9/30/2015 CASE 3  61 year old man with long standing peristent AF  s/p ablation for AF  Having symptoms here and there post ablation  Office ECG’s all NSR ALIVECOR Monitor 5

9/30/2015  ALIVECORE VIDEO 6

9/30/2015 Implantable Cardiac Devices and Atrial Arrhythmias  Over 400,000 pacemakers and implantable cardioverter–defibrillators (ICDs) implanted each year in North America  Asymptomatic Atrial Arrhythmias are frequently seen in patients undergoing device interrogation  Do subclinical episodes of AF increase the risk of stroke? Atrial Fibrillation Truths  Atrial fibrillation (AF) is the most commonly treated tachyarrhythmia worldwide. Population projections indicate that the prevalence of AF could exceed 5 million by 2050 in the United States alone.  AF raises the risk of stroke even in low risk patients  Oral Anticogulation Reduces the risk of stroke in AF 7

9/30/2015 ASSERT TRIAL ASSERT TRIAL  2580 patients with newly implanted ICD or PM  No history of AF  Assessed for the presence of subclinical atrial arrhythmia at 3 months and followed for 2.5 years  10% found to have subclinical atrial arrhythmia at 3 months, 34.7% at follow up (mean 2.5 years) 8

9/30/2015 Does AF Burden Correlate with Risk? Circ Arrhythmia Electrophysiol. 2009;2:474 ‐ 480 9

9/30/2015 TRENDS  2486 patients with 1 stroke risk factor (heart failure, hypertension, age 65 years, diabetes, or prior TE) with pacemakers or defibrillators capable of monitoring AF  AF burden was defined as the longest total AT/AF duration on any given day during the prior 30 ‐ day period  Annualized TE rates were determined according to AT/AF burden subsets:  zero, low <5.5 hours, high >5.5 hours TRENDS 10

9/30/2015 TRENDS Temporal Relationship between CVA and AF  In TRENDS 40 patients had TE (both AF and non AF patients)  50% of patients who experienced TE had AT/AF prior to the event.  Of the 20 patients with AT/AF prior to TE, 9 (45%) did not have any AT/AF within 30 days. 11

9/30/2015 Daoud, Heart Rhythm, 2011;8:1416 –1423 12

9/30/2015 TRENDS 13

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