ΑΣΥΜΠΤΩΜΑΤΙΚΗ ΚΟΛΠΙΚΗ ΜΑΡΜΑΡΥΓΗ

Transcription

1 ΑΣΥΜΠΤΩΜΑΤΙΚΗ ΚΟΛΠΙΚΗ ΜΑΡΜΑΡΥΓΗ ΓΕΩΡΓΙΟΣ ΣΤΑΥΡΟΠΟΥΛΟΣ Β ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ ΠΓΝΘ ΙΠΠΟΚΡΑΤΕΙΟ 9 Ο Βορειοελλα

2 ATRIAL FIBRILATION Atrial fibrillation (AF) is the most common clinically significant heart rhythm disorder, with an estimated lifetime risk of 22% to 26% or a lifetime risk of 1 in 4 In the European Union, there were 8.8 million adults >55 years of age with AF in 2010.Expected increase to 17.9 million by 2060 These statistics do not account for silent or undiagnosed AF, which is thought to affect as many as one third of the U.S. population

3 ATRIAL FIBRILATION AF associated morbidity: troublesome symptoms, heart failure, and thromboembolic events Drug and nonpharmacologic therapies that control rhythm or rate usually improve symptoms and heart failure The results of the therapy applied are usually judged on the basis of both the absence of clinical symptoms and documentation of sinus rhythm on every available electrocardiographic (ECG) recording Routine office ECGs, occasional 24-hour ambulatory ECG and, more seldom, longer term ECG event recording are the monitoring strategies usually adopted.

4 BENEFIT/RISK The concern is that asymptomatic and/or undetected recurrences of AF could expose patients to equally increased risks of stroke and thromboembolic events

5 ASYMPTOMATIC AF In about 25% of patients with ischemic strokes, no etiologic factor is identified Many patients with AF have no symptoms from the arrhythmia Many patients with episodes of AF (even permanent AF) may be unaware of the arrhythmia Patients with symptomatic episodes of AF also have many episodes asymptomatic asymptomatic intermittent AF is still poorly understood: inherently difficult to characterize and quantitate. Temporal relation between stroke/af! Prognostic significance of short episodes of asymptomatic AF, (as typically detected by pacemakers), is unknown

6 TEMPORAL DISSOCIATION BETWEEN SYMPTOMS AND AF Symptoms attributed to AF have a relatively low positive predictive value for AF Among patients with symptomatic bradycardia and a history of atrial fibrillation, symptoms of atrial fibrillation often were not associated with documented atrial tachyarrhythmias, and more than 90% of atrial tachyarrhythmias were clinically silent Strickberger et al Symptoms and Atrial Fibrillation Heart Rhythm, Vol 2, No 2, February 2005

7 ASYMPTOMATIC AF: INCIDENCE 38% asymptomatic reccurences JACC Vol. 43, No. 1, 2004 Israel et al. 49 Asymptomatic AF January 7, 2004:47 52

8 Cryptogenic Stroke and Underlying Atrial Fibrillation CRYSTAL

9 Low sensitivity and NP Value of classical monitoring tools Botto et al. AF and the Risk of Thromboembolic Events

10 DEVICE DETECTED ASYMPTOMATIC AF

11 Prognostic implications of asymptomatic AF

12 Circulation April 1, 2003 Glotzer et al AHREs Predict Death and Stroke

13 Atrial High Rate Episodes Predict Death and Stroke Presence of any AHRE(trial rate was 220 bpm for 5 minutes),meant that a patient was 2.5 times more likely to die 2.8 times more likely to die or have a nonfatal stroke nearly 6 times as likely to develop AF as one without any AHRE 6 year f up

14 ASYMPTOMATIC AF: PROGNOSTIC SIGNIFICANCE Capucci et al. JACC Vol. 46, No. 10, 2005 Arterial Embolism in Bradycardia Patients Italian AT500 Registry

15 2580 patients, 65 years, with hypertension and no history of atrial fibrillation, with a recently been implanted pacemaker or ICD. Subclinical atrial tachyarrhythmias :episodes of atrial rate >190 beats per minute for more than 6 minutes Follow up for a mean of 2.5 years for the primary outcome of ischemic stroke or systemic embolism

16 ASSERT Device detected Atrial Fibrilation 2,5 fold risk SCAF was detected by a pacemaker or an ICD in nearly 40% of patients during 2½ years of follow up lack of temporal association between SCAF and stroke or systemic embolism ASSERT does not provide any evidence that oral anticoagulation will have the same effectiveness in this population as it does for patients with clinical AF

17 Relationship between AF burden, as detected by an implanted CIED, and stroke/thromboembolism

18 RISC /BENEFIT (OACS) patients with CHADS2 score = 0 are at low risk, even if they have longlasting AF episodes patients with CHADS2 score 3 should be considered at high risk even when AF is no longer detected Botto et al. AF and the Risk of Thromboembolic Events

19 The net benefit of antithrombotic treatment is well established in patients with clinical atrial fibrillation, but there may not be a similar benefit in patients with subclinical atrial tachyarrhythmias

20 ARTESIA Apixaban for the Reduction of Thrombo-Embolism in patients with device detected Subclinical Atrial Fibrilation Primary outcome: Systemic stroke/systemic embolism and major bleeding Inclusion criteria: AF detection by Pacemaker/ICD/ILR 1 episode of subclinical AF 6min but no episode>24h,chads₂vasc score 4 Exclusion criteria: AF documented by surface ECG 6min,creatinine 2,5,creatinine clearence<25ml/min Randomisation:81mg ASA vs APIXABAN 2,5/5mg bid Mean follow up :3years

21 Non-vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes (NOAH) investigator-initiated, prospective, parallel-group, double-blind, randomised, multi-centre trial. Edoxaban vs ASA to pre-vent stroke, systemic embolism, or cardiovascular death in patients with AHRE 180 bpm atrial rate and 6 min duration and at least two stroke risk factors but without AF

22 ASYMPTOMATIC AF CONCLUSIONS combining data on AF absence, presence, and duration with CHADS2 score can discriminate between low- and high-risk patients within the same population the standard methods of AF monitoring have a low sensitivity and a low negative predictive value. This may impact on the management of antiarrhythmic and antithrombotic therapy, especially in patients with a moderate risk of embolic events absence of AF could guarantee low-moderate thromboembolic risk in patients with CHADS2 score 1, and 2, while it does not in patients with CHADS2 score 3

23 ASYMPTOMATIC AF CONCLUSIONS Current Guidelines still the only valid Device memory should not be ignored for AF management(though not mentioned in current Guidelines) Confirm it s really AF! Suggested treatment (on debate! Intervention trials still ongoing) : CHADS₂=0 : NO OAC CHADS₂=1-2: OAC if AF 24h duration and low bleeding risk CHADS₂ 3 : OAC if AF 6 min duration The threshold of the burden of asymptomatic, subclinical AF associated with a beneficial effect of oral anticoagulants remains unknown.

24 ΕΥΧΑΡΙΣΤΩ

25 ATRIAL FIBRILATION when AF is deemed to have been completely suppressed or cured, physicians may stop anticoagulation in an effort to avoid the unnecessary risks, burden, and inconvenience of OAC therapy The concern is that asymptomatic and/or undetected recurrences of AF could expose patients to increased risks of ischemic stroke and thromboembolic events

26 Documentation of atrial fibrillation is required to initiate anticoagulant therapy after ischemic stroke often paroxysmal and asymptomatic nature of atrial fibrillation, it may not be detected with the use of traditional monitoring techniques. Current guidelines suggest performing 24 or more hours of ECG monitoring to rule out atrial fibrillation in patients with an ischemic stroke but acknowledge that the most effective duration of monitoring has not been determined Most of the episodes of atrial fibrillation that were detected in our study were asymptomatic (74% at 6 months and 79% at 12 months in the ICM group). This finding, in combination with the paroxysmal nature of atrial fibrillation after cryptogenic stroke, may account for the low yield of diagnostic strategies based on symptom occurrence or the use of intermittent short-term recordings,(crystal)

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28 Botto et al. AF and the Risk of Thromboembolic Events

29 Embolic Stroke of unknown Source (ESUS) Approximately 25% of ischemic strokes appear cardioembolic (typical CT/MRI-clinical presentation) but no source can be detected by TOE-Holter. Paroxysmal asymptomatic undetected AF? Best detection achieved by Implantable Loop Recorder(ILR).