Atrialfibrillation. Assoc. Prof. Lucie Riedlbauchová, MD, PhD Department of Cardiology University hospital in Motol

Transcription

1 Atrialfibrillation Assoc. Prof. Lucie Riedlbauchová, MD, PhD Department of Cardiology University hospital in Motol ESC guidelines for the management of atrial fibrillation

2 Epidemiology Prevalence 1-2% Silent Afib Palpitation- not documented on ECG Men > women <0,5% y 5-15% >75 y Life-long risk of Afib development ~25% after age of 40 years Go AS, et al. JAMA 2001,285:

3 Expected prevalence of AFib in USA: 5,6 milion people in 2050! 7.0 Estimate of AFib prevalence between years Adult patients with Afib (in millions) Upper and lower curve = estimates of maximum and minimum depending of test sensitivity Years Go AS, et al. JAMA 2001,285:

4 Asymptomatic in many people No negative impact on haemodynamic Rate control strategy ~ rhythm control strategy? Why to care?

5 Consequences of atrial fibrillation 2x risk of death Death Mortality only with antitrombotic treatment 4,5x risk of stroke Stroke (ischemic + hemorrhagic) Cognitive dysfunction Hospitalization Quality of life More serious course of stroke 20% of strokes are related to Afib Parox. and silent Afib have similar risk Mikroembolization 2-3x risk of hospitalizations 1/3 of all hospitalizations for arhythmias Interindividually variable Exercise tolerance Left-ventricular function Ø efekt x tachycardia-induced cardiomyopathy Sudden death due to cardiac arrest in WPW Rapid conduction through accessory pathway

6 Atrial fibrillation - definition 1 Absolutely irregular RR intervals (absence of regularly irregular pattern ) 2 Atrial rate (if visible) >300 bpm (cycle length <200ms) 3 Absence of clear P waves on the surface ECG - except some leads (lead V1) often regular atrial activity

7 Atrial fibrillation HR (bpm) CL (ms) 3. Variable P wave morphology 2. Atrial rate >300 bpm (CL<200ms) CL FiS 160ms 1. Absolutely irregular RR intervals ms

8 1. Absolute irregularity of RR intervals CL 280ms = 214 bpm

9 1. Regularly irregular pattern Afib CL 500ms HR 120bpm

10 1. Regular ventricular rate in Afib

11 2. Tachycardia rate Afib HR > 300 bpm CL < 200ms HR 100 bpm CL 600ms HR 300 bpm CL 200ms

12 3. Variable P wave morphology Common atrial flutter Atypical atrial flutter Focal atrial tachycardia

13 3. Variable P wave morphology in AFib

14 3. Regular atrial activity in lead V1 during Afib

15 Afib pathogenesis Trigger(s) Arrhythmogenic substrate Afib begets Afib Parox.FiS Persist.FiS Electrical remodelling - shortening of ERP - local heterogeneity of ERP Genetic predisposition - i.e.lqts, Brugada, HCM Structural remodelling - intersticial fibrosis - inflammation - amyloid deposits in intersticium - myocyte apoptosis/ necrosis - hypertrophy and dediferenciation of myocytes - changes of microvasculature - endocard remodelling Focal ectopic activity (trig.activity, reentry) junction between PV and LA (parox.afib) focal activity in other locations (CS, posterior wall of LA, ) Multiple microreentry in left atrium

16 Patophysiologic consequences of Afib Hemodynamic changes - loss of atrial contribution to ventricular filling 5-15% decrease in CO - shortening of diastolic filling time in rapid heart rate - ventricular dyssynchrony ventricular dysfunction tachycardia-induced cardiomyopathy Tromboembolism - blood statis in fibrillating atrium - contractility of LA appendage - progressive atrial dilatation - endocard changes (denudation, changes in ECT matrix) - platelet activity and hemostasis - inflammatory markers and growth factors

17 Units associated with Afib Lone atrial fibrillation Cardiovascular pathologies - arterial hypertension - symptomatic heart failure (up to 30%) - tachycardia-induced cardiomyopathy - valve athologies (up to 30% pts with Afib) - coronary artery disease (up to >20% pts with Afib) - cardiomyopathy - atrial septal defect, other congenital heart diseases Non-cardial pathology - age - thyreoid dysfunction (clinically manifest or subclinical) - obesity (up to 25% of pts. with Afib) - COPD (up to 10-15% pts. with Afib) - diabetes mellitus (up to 20% pts. with Afib) - sleep apnea syndrome - chron.renal disease (up to 10-15% pts)

18 Diagnosis 1 pt. history Asymptomatic AFib Symptomatic Afib - irregular palpitation, dyspnea, decreased exercise tolerance Palpitation regular / irregular? Triggers (exercise, stress, emotion, alcohol, )? Frequency and duration of an episode? Familiar history? Associated cardiovascular/ non-cardiac pathologies? Symptom severity during Afib (EHRA score) EHRA I EHRA II No symptoms Mild symptoms not affecting regular daily activity EHRA III EHRA IV Moderate symptoms thah limit regular daily activity Severe symptoms limiting regular daily activity Manifestation in form of stroke/tia - 10% risk of TIA/ stroke recurrence in the following year

19 Diagnosis 2: ECG 12-lead ECG Long-term ECG monitoring 24 hour Holter 7 day ECG Holter exteral event recorder/ loop recorder Permanent ECG monitoring implantabile loop recorder permanent pacemaker ICD (implantabilile cardioverter-defibrilator) Diagnosis 3: Other exams ECHO Thyreoid gland hormones Blood count Biochemistry (U,Kr, glucose, hepatal tests, ionts, ) Exercise test ans coronary angiography when CAD suspected

20 Types of Afib Paroxysmal Afib Persistent Afib - spontaneous termination - termination usually 48 hours (7days) - Afib lasting 7 days or - Afib requiring cardioversion (pharmak.,electrical) Long-standing persistent Afib Permanent/ chronic Afib - Afib lasting 1 year when rhythm control is persued - Afib accepted by both physician and patient - rate control strategy First detection of Afib

21 Afib therapy This is a new slimming pill. It is not for swallowing, it is for running.

22 Afib therapy 1. Antithrombotic therapy prevention of tromboembolic complications 2. Modification of symptoms ans hemodynamic impact of Afib Rhythm control strategy Rate control strategy 3. Treatment of underlying disease, upstream therapy

23 interindividually variable dose slow onset and termination influence of food/ drugs checks of INR necessary INR 2-3 only in 60% of time only 60% of pts. With high risk of stroke Warfarin Direct inhibitors of Xa: Fondaparinux (Arixtra) Idraparinux Apixaban (Eliquis) p.o. Rivaroxaban (Xarelto) p.o. (Edoxaban) Direct inhibitors of thrombin: Dabigatran (Pradaxa) p.o. Argatroban (Acova) i.v. Bivalirudin (Angiomax) i.v. Desirudin

24 Antithrombotic treatment Thromboembolic risk stratification CHADS2 score CHADS2 2 anticoagulation Cardiac failure 1 bod Hypertension 1 Age (>75let) 1 Diabetes 1 Stroke (doubled) 2 CHADS2 score Stroke rate (%/ year) 0 1,9 % 1 2,8 % 2 4,0 % 3 5,9 % 4 8,5 % 5 12,5 % 6 18,2 % CHADS2 = 0 low risk pts. nothing / ASA CHADS2 = 1-2 moderate risk pts.??? CHADS2 > 2 high risk pts. warfarin Limits of CHADS2: - most pts. Are in grey zone of moderate risk pts - does not include all risk factors of tromboembolic complication

25 Thromboembolic risk stratification CHA2DS2-VASc score Major risk factors (2 points) History of stroke/tia/embolization Age 75 years Minor risk factors (1 point) Heart failure or LVEF 40% Hypertension Diabetes Female gender Age year Vascular disease Cardiac failure/ LV dysfunction (EF 40%) 1 bod Hypertension 1 Age 75 years 2 Diabetes mellitus 1 Stroke/ TIA/ trombo-embolism 2 Vascular disease (IM, complex aortic plaques,...) 1 Age years 1 Sex (female) 1 CHA2DS2 Stroke risk -VASc (%/ year) 0 0% 1 1,3% 2 2,2% 3 3,2% 4 4,0% 5 6,7% 6 9,8% 7 9,6% 8 6,7% 9 15,2%

26 Selection of antithrombotic treatment Atrial fibrillation Non-valvular Afib Valvular Afib Yes < 65 years or lone Afib ( i ) Risk of stroke Score CHA2DS2-VASc Anticoagulation (warfarin) No antithrombotic therapy Peroral anticoagulation - type (vit.k antagonists x other p.o. anticoagulants) selected based on the (HAS-BLED score), patient preferences (and local policy of health insurances)

27 Thromboembolic risk stratification Bleding risk stratification HAS-BLED score 0-9 points H Hypertension 1 point Abnormal liver A and renal function 1 or2 (1 point foreach) S Stroke 1 B Bleeding 1 L Labile INR 1 E Elderly(>65 years) 1 D Drugsoralcohol (1 point foreach) 1 or2 HAS-BLED 3 = high risk of bleeding

28 Antithrombotic therapy Hemodynamically stable Afib Duration <48hours Duration >48hours 3 weeks of anticoagulation TEE - LA thrombus Heparin + cardioversion Cardioversion Heparin No Yes Sinus Afib Sinus 3 weeks of anticoagulation + rate control Thromboembolic risk factors? Ne Yes 4 weeks of anticoagulation Thromboembolic risk factors? No TEE - LA thrombus Yes No long-term anticoagulation No Yes Long-term anticoagulation

29 2. Afib treatment Rhythm control Rate control strategy Acute therapy Long-term therapy Rate control mandatory always! rate x rhythm control strategy acute x long-term treatment Afib with rapid HR HR slowing target Hr bpm (drugs affecting AV conduction (BB, isoptin, digoxin) Afib with slow HR HR acceleration (atropin, temporary pacing)

30 Acute treatment Afib < 48 hours Afib < 48 hours Hemodynamically unstable? (ongoing ischemia, symptomatic hypotension, angina, heart failure, Afib in WPW syndrome) Yes No Pill-in-the-pocket Electrical cardioversion (with/ without antiarrhythmic premedication) Structural heart disease? Yes No DC contraindicated in digitalis intoxication! Amiodarone i.v. Flecainid i.v. Propafenon i.v. (Prajmalin i.v.) Pharmacological cardioversion less effective, + no analgosedation required Propafenon Flecainide 2mg/kg i.v. during 10min 2mg/kg i.v. during 10min mg p.o mg p.o. KI in pts- with organic heart diseasee Side effect: QRS and QT prolongation, Afib conversion into 1:1 atrial flutteru Amiodarone 5mg/kg i.v. during 1 hour - Phlebitis, hypotension, QT prolongation

31 Acute treatment Afib > 48 hours Afib > 48 hours or uncertain agetáří Hemodynamically non-stable? Yes No Rhythm control Rate control TEE + cardioversion Afib with rapid HR HR slowing target HR bpm (drugs affecting AV conduction (BB, isoptin, digoxin) Afib with slow HR HR acceleration (atropin, temporary pacing)

32 Long-term treatment Rhythm control x rate control Rhythm control Rate control Symptomatic Afib (EHRA 2) despite adequate rate control Afib with signs of heart failure (altered haemodynamic) Asymptomatic Afib/ minimally symptomatic Afib (EHRA 0-1) FiS in older pts Afib in younger symptomatic pts Afib secondary due to other disease that had been corrected (ischemia, hyperthyreoidism) Rate control is indicated even after sinus rhythm restoration due to the risk of rapid ventricular rate in the case of Afib recurrence

33 Long-term treatment rate control Pharmacotherapy Afib with slow HR acceleration (permanent pacing) Afib with rapid HR slowing (drugs affecting AV conduction - BB, isoptin, digoxin, (amiodaron)) Selection of antiarrhythmic drug for rate control - depends on life style and comorbidities Inactive patient Active life style Comorbidity No/ Arterial hypertension Heart failure COPD Digoxin Beta-blockers Verapamil/ diltiazem Digoxin Beta-blockers Digoxin Verapamil/ diltiazem Digoxin B1-selective beta-bloskers + amiodaron/ dronedarone are drugs of second choice Rate control of Afib in WPW IC antiarrhythmic drugs, amiodarone - Drugs modifying AV conduction (BB, Ca blockers, digoxin, adenosin) are KI for risk of cardiac arrest

34 Long-term treatment rate control Non-pharmacological treatment Nonselective ablation/ modification of AV junction + PM implantation

35 Long-term treatment rhythm control Pharmacotherapy Pharmacotherapy - Main indication reduction/ elimination of Afib-related symptoms - Probability of sinus rhythm maintenance is 2x higher after antiarrhythmics - Successful pharmacotherapy rather reduces Afib recurrence rather than eliminates its recurrences - Failure of 1 antiarrhythmis drug change of therapy - Side effect of drugs and their potential proarrhythmic effect Drugs affecting AV conduction (BB, digoxin, isoptin) are not intended for rhythm control!!! Nonpharmacological treatment Selective Afib ablation

36 Long-term treatment rhythm control Pharmacotherapy No heart disease Minimal structural disease (incl.hypertension without LV hypertrophy)? Prevention of remodelling ACEI/ARB/statins/BB? Significant structural heart disease Treatment of underlying disease and?prevention of remodelling/reverse remodelling of LA (ACEI/ARB/statins/BB?)? Adrenergic Afib (stres, exercise) Vagal Afib (rest, sleeping) Undetermined AfibHypertension Ischemic heart disease Heart failure with LV hypertrophy Stable NYHA I/II Unstable.NYHA II or NYHA III/IV Beta-blockers Sotalol Disopyramid Propafenon Flecainid Sotalol Dronedaron Dronedaron Dronedaron Sotalol Dronedaron Dronedarone Amiodaron Amiodaron Amiodaron Amiodaron Amiodaron Amiodaron ACEI ACE inhibitors, ARB sartans, BB betablockers, LA left atrium

37 Long-term treatment rhythm control Afib ablation Indication: Symptomatic Afib despite optimal pharmacological treatment (failure of at least 1 antiarrhythmic drug) Success rate: 77% Ablation x 52% antiarrhythmic drug Factors affecting success rate of Afib ablation: - Afib type and history - LA size - Presence and severity of underlying heart diseases?? Does Afib ablation modifies mortality?? How to exclude presence of asymptomatic AFib recurrences after Afib ablation?

38 Potencial complication of Afib ablation

39 Howto surviveafib Afibtreatment