ROLE OF IMAGING IN ARRHYTHMIA/DEVICES I ATRIAL FΙBRILLATION: CLINICAL TYPES AND OUTCOME (PROGNOSIS)

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1 ROLE OF IMAGING IN ARRHYTHMIA/DEVICES I ATRIAL FΙBRILLATION: CLINICAL TYPES AND OUTCOME (PROGNOSIS) Κώστας Παπαδόπουλος, Επιμ. Α Καρδιολογίας, Νοσοκομείο Ερυθρός Σταυρός

2 ATRIAL FIBRILATION - EPIDEMIOLOGY 25% middle-aged adults in Europe and the US will develop AF AF prevalence of 3% in 20 years adults aged > 10% in pts>80 years AF is independently associated with a two-fold increased risk of all-cause mortality in women and a 1.5-fold increase in men -Chugh SS, et al. Circulation 2014;129: Colilla S, et al.am J Cardiol 2013;112: Go AS, et al. JAMA 2001;285: Zoni-Berisso M, et al. Clin Epidemiol 2014;6: Haim M, et al. J Am Heart Assoc 2015;4:e

3 PATHOPHYSIOLOGICAL AND GENETIC ASPECTS 2016 ESC Guidelines for the management of AF. European Heart Journal 2016;37:

4 CLASSIFICATION IN AF Overt (symptom burden) or silent AF Atrial fibrillation pattern based on the presentation, duration, and spontaneous termination of AF episodes Atrial fibrillation clinical types reflecting different causes of the arrhythmia ΑΙΜ: Better management of the arrhythmia and prevention of the recurrences and complications

5 OVERT OR SILENT AF Diagnosis of AF requires rhythm documentation using ECG, showing the typical pattern of AF AF: an episode lasting at least 30s is diagnostic. Symptomatic or asymptomatic ( silent AF ), or both SILENT AF - Common, with severe consequences such as stroke and death - Undiagnosed AF was found in 1.4% of those aged >65 years, - ECG monitoring detected AF in 12-24% of stroke survivors, with large variations depending on the timing, duration, and method of monitoring - Kishore A, et al. Stroke 2014;45: Savelieva I, et al. J Interv Card Electrophysiol 2000;4: Vanassche T, et al. Eur Heart J 2015;36: a

6 RECOMMENDATIONS FOR SCREENING FOR AF 2016 ESC Guidelines for the management of AF. European Heart Journal 2016;37:

7 ATRIAL HIGH RATE EPISODES (AHRE) In 10 15% of pacemaker patients Not all AHRE represent AF. Associated with an increased risk of overt AF and ischaemic stroke or systemic embolism Lower than the stroke risk in patients with diagnosed AF Unclear whether AHRE imply the same therapeutic requirements as overt AF - Santini M, et al. J Am Coll Cardiol 2011;57: Daoud EG, et al. Heart Rhythm 2011;8: Lamas G. N Engl J Med 2012;366:

8 ATRIAL FIBRILLATION PATTERN Five types of AF based on the presentation, duration, and spontaneous termination of AF episodes 2016 ESC Guidelines for the management of AF. European Heart Journal 2016;37:

9 AF progresses from short, infrequent episodes to longer and more frequent attacks Over time, many patients will develop sustained forms of AF. 2 3% of AF patients will remain paroxysmal over several decades AF patterns do not correspond well to the AF burden This classification alone is often insufficient to select specific therapies -Banerjee A, et al. Int J Cardiol 2013;167: Jahangir A, et al. Circulation 2007;115: Vanassche T, et al. Eur Heart J 2015;36: a. -Kirchhof P, et al. Europace 2013;15:

10 CLINICAL TYPES OF ATRIAL FIBRILLATION The risk of developing AF is increased in a variety of physiological and disease states Τhe historic term lone AF is probably misleading and should be avoided Although the pattern of AF may be the same, the mechanisms underpinning AF vary substantially between patients Clinical types reflect different causes of the arrhythmia - Chao TF, et al. Am J Cardiol 2010;106: Albertsen IE, Chest 2014;145: Overvad TF, et al. Heart 2013;99: Daccarett M, J Am Coll Cardiol 2011;57:

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12 Stratifying AF patients by underlying drivers of AF could inform management considering: - cardiac and systemic comorbidity (e.g.diabetes and obesity), - lifestyle factors (e.g. activity level, smoking, alcohol intake), - genetic background. These types of AF will overlap in clinical practice, Their impact for management needs to be evaluated systematically. - Chao TF, et al. Am J Cardiol 2010;106: Albertsen IE, Chest 2014;145: Overvad TF, et al. Heart 2013;99: Daccarett M, J Am Coll Cardiol 2011;57:

13 PROGNOSIS

14 2016 ESC Guidelines for the management of AF. European Heart Journal 2016;37:

15 PROGNOSTIC FACTORS Many cardiovascular diseases and concomitant conditions increase the risk of developing AF, recurrent AF, and AFassociated complications The identification of such conditions, their prevention and treatment is an important leverage to prevent AF and its disease burden Knowledge of these factors and their management is hence important for optimal management of AF patients -Pathak RK, et al. J Am Coll Cardiol2014;64: Abed HS, et al. JAMA 2013;310:

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17 HEART FAILURE HF and AF coincide in many patients Similar risk factors and common pathophysiology Structural cardiac remodelling, activation of neurohormonal mechanisms, and rate-related impairment of LV function. Patients with AF and concomitant HF, suffer from a worse prognosis, including increased mortality. HF risk factor of Stroke in pts with AF Standard HF therapy, Anticoagulation Rate control of AF: only beta-blockers and digoxin in HFrEF Rhythm control: Amiodarone - Kotecha D,et al. Int J Cardiol 2016;203: Mamas MA, et al. Eur J Heart Fail 2009;11: Lip GY, et al. Europace 2016;18:12 36.

18 HYPERTENSION Cause and prognostic factor of AF Stroke and bleeding risk factor in AF Beneficial effect of ACE inhibitors or ARBs in pts with AF (lower incidence of new-onset AF) ACE inhibitors or ARBs may reduce recurrent AF after cardioversion - Manolis AJ, et al. J Hypertens 2012;30: Goette A, et al. J Am Coll Cardiol 2000;35:

19 VALVULAR HEART DISEASE Independently associated with incident AF 30% of patients with AF have some form of valvular heart disease AF worsens prognosis in patients with severe VHD, and is a marker for progressive VHD VHD can be associated with an increased thrombo-embolic risk, which probably also adds to the stroke risk in AF patients Valvular AF mainly refers to AF patients that have either rheumatic VD (predominantly mitral stenosis) or mechanical heart valves. AF implies an incremental risk for thrombo-embolism in patients with mitral valve stenosis. - Kotecha D,et al. Int J Cardiol 2016;203: Mamas MA, et al. Eur J Heart Fail 2009;11: Lip GY, et al. Europace 2016;18:12 36.

20 DIABETES MELLITUS Diabetes and AF frequently coexist because of associations with other risk factors. Diabetes is a risk factor for stroke and other complications in AF Treatment with metformin seems to be associated with a decreased long-term risk of AF in diabetic patients and may even be associated with a lower long-term stroke risk. -Ziolo MT, et al. J Cardiovasc Electrophysiol 2015;26: Fatemi O, et al. Am J Cardiol 2014;114: Overvad TF, et al. Stroke 2015;46:

21 OBESITY Obesity increases the risk for AF according to body mass index (BMI). Obese patients may have more LV diastolic dysfunction, increased sympathetic activity and inflammation, and increased fatty infiltration of the atria Obesity may also be a risk factor for ischaemic stroke, thrombo-embolism, and death in AF patients. Positive effect of weight reduction in obese AF patients (fewer AF recurrences and after catheter ablation) - Wanahita N, et al. Am Heart J 2008;155: Pathak RK, et al. J Am Coll Cardiol 2015;65: Guijian L, et al. Pacing Clin Electrophysiol 2013;36:

22 RESPIRATORY DISEASES AF has been associated with obstructive sleep apnoea Risk factor reduction and continuous positive airway pressure ventilation can reduce AF recurrence Atrial tachycardias mainly in CODP Theophyllines and beta-adrenergic agonists, may precipitate AF Non-selective BB, sotalol, propafenone, and adenosine should be used with caution in patients with significant bronchospasm, Selective BB, diltiazem, and verapamil are often tolerated and effective - Digby GC, et al. Curr Cardiol Rev 2012;8: Lin YK, et al. Clin Sci (Lond) 2012;122: Linz D, et al.. Am J Cardiol 2012;110:1071.

23 CHRONIC KIDNEY DISEASE AF is present in 15 20% of patients with CKD. CrCl in AF patients can deteriorate over time Bleeding risk factor - Hart RG, et al. Can J Cardiol 2013;29:S Roldan V, et al. Am J Cardiol 2013;111:

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25 HAS-BLED score Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65 years), Drugs/alcohol concomitantly (1 point each)

26 ECHOCARDIOGRAPHY IN ATRIAL FIBRILLATION ECHO provide insights into the: CARDIAC FUNCTION AETIOLOGY - DIAGNOSIS of the underlying structural heart disease PROGNOSIS / RISK STRATIFICATION MANAGEMENT DECISIONS - Guiding cardioversion - Medical therapy for Rhythm or Rate control - Interventions (Ablation, Closure devices) 2014 AHA/ACC/HRS Guidelines for the Management of Patients With AF. JACC 2014;64:e EACVI/EHRA Expert Consensus Document on the role of multi- modality imaging for the evaluation of AF. EurHJCVI 2016

27 PROGNOSIS / RISK STRATIFICATION Bax J, et al. Heart 2015;101:

28 LV systolic dysfunction (LVEF<40%): associated with an increased risk of thromboembolism (stroke). Lip GY, et al. Chest 2010;137: GLS: GLS is a stronger parameter than LVEF and Sa in predicting adverse CV events (CV death, non-fatal stroke and hospitalisation for heart failure) and could offer an additional prognostic benefit over conventional clinical and echocardiographic systolic parameters in AF.. Su HM, et al. Heart 2013;99:

29 Left Atrial diameter >50mm: independent predictors of the presence of SEC and thrombus. LA strain: <30%, indicates significant alteration of LA reservoir function, which predicts the poor outcome.. LV diastolic dysfunction is an independent predictor of AF in the elderly. -Tsang TS, et al.. J Am Coll Cardiol 2002;40: Echo predictors of stroke in patients with atrial fibrillation. Arch Intern Med 1998;158: Kleemann T, et al. Eur J Echocardiogr 2009;10:383 8.

30 Assessment of stroke risk in not anticoagulated or inadequately anticoagulated patients TRANSESOPHAGEAL ECHO TOE-guided cardioversion is an alternative to anticoagulation if AF lasts > 48 h in patients who were not anticoagulated or were inadequately anticoagulated during the last 3 weeks prior to cardioversion (class IIaB) -EACVI/EHRA Expert Consensus Document on the role of multi- modality imaging for the evaluation of AF. EurHJCVI AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC 2014;6 4: 2 1

31 CMR ASSOCIATION OF LEFT ATRIAL FIBROSIS DETECTED BY DELAYED ENHANCEMENT MAGNETIC RESONANCE IMAGING AND THE RISK OF STROKE IN PATIENTS WITH ATRIAL FIBRILLATION Relationship of LA Structural Remodeling / Fibrosis and Stroke and CHADS 2 score. Daccarett M, et al. J Am Coll Cardiol 2011;57:831 8.

32 CONCLUSIONS CLASSIFICATION in AF Overt (symptom burden) or silent AF AF pattern based on the presentation, duration, and spontaneous termination of AF episodes AF clinical types reflecting different causes of the arrhythmia ΑΙΜ: Better management of the arrhythmia and prevention of the recurrences and complications PROGNOSIS Many cardiovascular diseases and concomitant conditions increase the risk of developing AF, recurrent AF, and AFassociated complications and their management is important for optimal management of AF patients