Manuel Castella MD PhD Hospital Clínic, University of

Transcription

1 Manuel Castella MD PhD Hospital Clínic, University of

2 European Heart Journal - doi: /eurheartj/ehw210 Providing integrated care for AF patients Integrated AF management 2 Patient involvement Technology Access to all treatment Multidisciplinary teams tools options for AF Central role in care process. Physicians (general physicians, Information on AF. Structured support for lifestyle Patient education. Encouragement and empowerment for self-management. Advice and education on lifestyle and risk factor management. Shared decision making. cardiology and stroke AF specialists, surgeons) and allied health professionals work in a collaborative practice model. Efficient mix of communication skills, education, and experience. Clinical decision support. Checklist and communication tools Used by healthcare professionals and patients. Monitoring of therapy adherence and effectiveness. changes. Anticoagulation. Rate control. Antiarrhythmic drugs. Catheter and surgical interventions (ablation, LAA occluder, AF surgery, etc.). Informed, involved, empowered Working together in a multi- Navigation system to support Complex management decisions patient. disciplinary chronic AF care team. decision making in treatment underpinned by an AF Heart Team team.

3 European Heart Journal - doi: /eurheartj/ehw210 3 Stroke prevention in atrial fibrillation Mechanical heart valves or moderate or severe mitral stenosis Yes No Estimate stroke risk based on number of CHA 2 DS 2 -VASc risk factors 0 a 1 2 No antiplatelet or anticoagulant treatment (IIIB) OAC should be considered (IIaB) Oral anticoagulation indicated Assess for contra-indications Correct reversible bleeding risk factors LAA occluding devices may be considered in patients with clear contra-indications for OAC (IIbC) a Includes women without other stroke risk factors b IIaB for women with only one additional stroke risk factor c IB for patients with mechanical heart valves or mitral stenosis NOAC (IA) b VKA (IA) c

4 European Heart Journal - doi: /eurheartj/ehw210 Initiation or continuation of anticoagulation in atrial fibrillation patients after a stroke or transient ischaemic attack 4 Patient with atrial fibrillation and acute TIA or ischaemic stroke Exclusion of intracerebral bleeding by CT or MRI TIA Mild stroke (NIHSS <8) Moderate stroke (NIHSS 8 15) Severe stroke (NIHSS 16) Factors favouring early initiation of OAC: Low NIHSS (<8): Small/no brain infarction on imaging High recurrence risk, e.g. cardiac thrombus No need for percutaneous endoscopic gastrostomy No need for carotid surgery No haemorrhagic transformation Clinically Factors favouring delayed initiation of OAC: High NIHSS ( 8): Large/moderate brain infarction on imaging Needs gastrostomy or major surgical intervention Needs carotid surgery Haemorrhagic transformation Neurologically unstable Elderly patient Uncontrolled hypertension Evaluate haemorrhagic transformation by CT or MRI at day 6 Evaluate haemorrhagic transformation by CT or MRI at day 12 Start OAC 1 day after acute event 3 days after acute event 6 days after acute event 12 days after acute event

5 European Heart Journal - doi: /eurheartj/ehw210 Initiation or resumption of anticoagulation in atrial fibrillation patients after an intracranial bleed 5 Patient with AF suffering from an intracranial bleed on OAC If acute event: establish intensity of anticoagulation (see bleeding flow chart) Contra-indication for OAC Factors favouring withholding of OAC: Bleeding occurred on adequately dosed NOAC or in setting of treatment interruption or underdosing Older age Uncontrolled hypertension Cortical bleed Severe intracranial bleed Multiple microbleeds (e.g. >10) Cause of bleed cannot be removed or treated Chronic alcohol abuse Need for dual antiplatelet therapy after PCI Factors supporting reinitiation of OAC: Bleeding occurred on VKA or in setting of overdose Traumatic or treatable cause Younger age Well controlled hypertension Basal ganglia bleed No or mild white matter lesions Surgical removal of subdural haematoma Subarachnoid bleed: aneurysm clipped or coiled High-risk of ischaemic stroke Patient or next of kin choice informed by multidisciplinary team advice No stroke protection (no evidence) LAA occlusion (IIbC) Initiate or resume OAC, choosing an agent with low intracranial bleeding risk, after 4 8 weeks (IIbB)

6 European Heart Journal - doi: /eurheartj/ehw210 6 Management of bleeding in anticoagulated AF patients Patient with active bleeding Compress bleeding sites mechanically Assess haemodynamic status, blood pressure, basic coagulation parameters, blood count, and kidney function Obtain anticoagulation history (last NOAC / VKA dose) VKA NOAC Delay VKA until INR <2 Add symptomatic treatment: Fluid replacement Blood transfusion Treat bleeding cause (e.g. gastroscopy)consider to addvitamin K (1 10 mg) Consider PCC and FFP Consider replacement of platelets where appropriate Minor Moderate - Severe Severe or life-threatening Delay NOAC for 1 dose or 1 day Add symptomatic treatment: Fluid replacement Blood transfusion Treat bleeding cause (e.g. gastroscopy)consider to add oral charcoalif recently ingested NOAC Consider specific antidote, or PCC if no antidote available. Consider replacement of platelets where appropriate

7 European Heart Journal - doi: /eurheartj/ehw210 Antithrombotic therapy after an acute coronary syndrome in atrial fibrillation patients requiring anticoagulation 7 AF patient in need of OAC after an ACS Time from ACS 0 1 month 3 months 6 months 12 months lifelong Bleeding risk low compared to risk for ACS or stent thrombosis Triple therapy (IIaB) Dual therapy (IIaC) A or C OAC monotherapy (IB) Bleeding risk high compared to risk for ACS or stent thrombosis Triple therapy (IIaB) Dual therapy (IIaC) A or C OAC monotherapy (IB) OAC Aspirin mg daily Clopidogrel 75 mg daily

8 European Heart Journal - doi: /eurheartj/ehw210 8 Acute heart rate control in atrial fibrillation Acute heart rate control of AF LVEF <40% or signs of congestive heart failure LVEF 40% Smallest dose of beta blocker to achieve rate control Amiodarone is an option in patients with haemodynamic instability or severely reduced LVEF Initial resting heart rate target <110 bpm Add digoxin Initial resting heart rate target <110 bpm Beta blocker or diltiazem or verapamil Check previous drug history to avoid concomitant administration Initial resting heart rate target <110 bpm Add digoxin Initial resting heart rate target <110 bpm Avoid bradycardia Perform echocardiogram to determine further management/ choice of maintenance therapy Consider need for anticoagulation

9 Evidence-based medicine Randomized controlled trials: Benefits in rhythm Better quality of life Higher rate of permanent pacemakers Non-randomized studies: Better survival Freedom from stroke Better ventricular function

10 Current Guidelines Recommendations 2016 ESC/EACTS Guidelines Class Level Maze surgery, preferably biatrial, should be considered in patients undergoing cardiac surgery to improve symptoms attributable to AF, balancing the added risk of the procedure and the benefit of rhythm control therapy. IIa A Recommendations 2017 STS Guidelines Class Level Surgical ablation for AF can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm I A Surgical ablation for AF can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant isolated AVR, isolated CABG, and AVR plus CABG to restore sinus rhythm I Bnr

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20 Pacemaker need increased from 4,3% non-maze to 6,4% Maze patients

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22 2016 ESC/EACTS Guidelines 2 2 AF as trigger for mitral surgery Recommendations Class Level Early mitral valve surgery should be considered in severe mitral regurgitation, preserved LV function, and new-onset AF, even in the absence of symptoms, particularly when valve repair is feasible. IIa C

23 Current guidelines for Lone AF Recommendations 2016 ESC/EACTS Guidelines Class Level Minimally invasive surgery with epicardial pulmonary vein isolation should be considered in patients with symptomatic AF when catheter ablation has failed. Decisions on such patients should be supported by an AF Heart Team. Catheter or surgical ablation should be considered in patients with symptomatic persistent or long-standing persistent AF refractory to AAD therapy to improve symptoms, considering patient choice, benefit and risk, supported by an AF Heart Team. IIa IIa B C Recommendations 2017 STS Guidelines Class Level Surgical ablation for symptomatic AF in the abscence of structural heart disease that is refractory to AAD or catheter-based therapy is reasonably as a primary stand-alone procedure to restore sinus rhythm Surgical ablation for symptomatic persistent or L-S persistent AF in the abscence of structural disease is reasonable as a stand-alone procedure using the Cox-Maze III/IV lesion set compared to PVI alone IIa IIa B Bnr

24 In conclusion ESC/EACTS 2016 Guidelines: Complete management of AF patients Probably too biased for RCT-only evidence Need for more precise guide on to whom to treat based on risks for failure/complications