State of the Art Management on Atrial Fibrillation in Monica Lo, MD, FACC, FHRS April 15, 2016
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1 State of the Art Management on Atrial Fibrillation in 2016 Monica Lo, MD, FACC, FHRS April 15, 2016
2 Scope of the Problem More than 30 million people worldwide 1 5 million new cases each year 1 in 4 lifetime risk 2 Increased risk of 3 Stroke (5x) Dementia (2x) MI/HF Death 1 Chugh SS et al. Circulation 2014;129: Lloyd-Jones DM et al. Circulation 2004;110: Go AS et al. Circulation 2014;129:e28 e292.
3 AF Is Costly Hospital admissions increased by twothirds in the last 2 decades 2x more likely to be admitted 3x more likely to have multiple admissions More than $26 billion annually More than 460,000 admissions annually as primary diagnosis Go AS et al. Circulation 2014;129:e28 e292.
4 AF Risk Factors Genetics - chromosome 4q25 Age Hypertension Obesity CHF CAD Valvular heart disease Tucker NR. Circ Res 2014;114:
5 Reversible Causes of AF Binge drinking Post-operative MI Pericarditis/myocarditis Hyperthyroidism Pneumonia Pulmonary emoblism WPW/AVNRT/AT
6 Definitions
7 Pathophysiology of AF Triggers Substrate/Rotors Calkins, HRJ 2012.
8 What Are the Symptoms? Palpitations Fatigue Decreased exercise tolerance Dyspnea (with or without exertion) Dizziness/syncope Hypotension CHF Not feeling well CVA/TIA
9 Silent AF Is Not Benign (Device Monitoring Data) Trials Episodes Outcome ASSERT >190bpm, >6min >5x subsequent AF 1.6%/yr CVA MOST >220bpm, >10beats 6x subsequent AF >2x death/cva Glotzer et al AT/AF >5.5hrs 2.4%/yr thromboem Shanmugam et al AT/AF >3.8hrs (CHF) >9x thromboem
10 AF/AFl Management Goals Reduce symptoms Improve quality of life Prevent progression of AF Prevent progression of heart failure STROKE PREVENTION
11 AF/AFl Stroke Prevention Use the CHA2DS2 VASC score CHF (1) HTN (1) Age 75 (2) DM (1) Stroke (2) Vascular (1) Age 65 (1) Sex female (1)
12 AF/AFl Stroke Prevention CHA2DS2 VASC Score Annual Stroke Risk (%) 0 < % under-treatment
13 HAS-BLED Score Hypertension, >160 Abnl liver or renal Stroke Bleeding history Labile INR Elderly, >65 Drugs or EtOH Risk Score Bleeding Risk (%)
14 Anticoagulation Agents Warfarin NOACs (Non-Valvular AF only) Pradaxa (Direct thrombin inhibitor) 150mg dose superior to warfarin Interacts with Multaq, use reduced dose GI discomfort Xarelto (Factor Xa inhibitor) Take with food More GI bleeding but less ICH compared to warfarin Once a day dosing, take with dinner Eliquis (Factor Xa inhibitor) Superior to warfarin Better bleeding profile CKD/ESRD on stable HD
15 WATCHMAN Left Atrial Appendage Closure (LAAC) Device Procedure One-time implant that does not need to be replaced Performed in a cardiac cath lab/ep suite, does not need hybrid OR Performed by a Heart Team IC/EP or IC&EP, TEE, General Anesthesia, Surgical Back- up, WATCHMAN Clinical Specialist Transfemoral Access: Catheter advanced to the LAA via the femoral vein (Does not require open heart surgery) General anesthesia* 1 hour procedure* 1-2 day hospital stay* * Typical to patient treatment in U.S. clinical trials
16 Rate Control Ultimate rate control - PPM/AVJ RF
17 Rhythm Control
18 A Word on Amiodarone Limit its use! Toxicity is REAL Dose/duration Some irreversible Drug interactions Selected population: Elderly, impaired renal function, CHF, post-operative
19 Favoring Rhythm Control Improvements of symptoms and QoL Difficulty achieving rate control Younger patient age Tachycardia-medicated CMP Prevent irreversible electrical and structural remodeling Prevent progression of CHF Prevent progression of AF
20 AF Progression Rhythm Rate 164/1542 (11%) p< /595 (26%) N = month F/U 15% paf persistent or permanent AF 0% 50% 100% De Vos (RecordAF), AHJ 2012.
21 Rate vs. Rhythm Control A CURE = ablate typical atrial flutter!
22 Case - Atrial Flutter 60 year-old woman with atrial flutter leading to tachy-induced cardiomyopathy, EF 15-20%, h/o TIA/CVA A/C renal insufficiency (Cr 1.6 -> 3.7) Volume overloaded (pbnp 10,000) Elevated LFTs Distended abd with KUB showing ileus H/O DCCV x2 HR 120s, on IV diltiazem and Xarelto
23 Case Atrial Flutter
24 Atrial Fibrillation Ablation Pulmonary Vein Isolation N = 45 Initiators of AF PACs Haissaguerre, NEJM 1998.
25
26 PVI Is More Efficacious p< Pappone, JACC 2003.
27 Case Atrial Fibrillation 47 year-old obese man with AF, HTN, DM AF recurred on Tikosyn EF 35% when in AF Loaded on amiodarone s/p DCCV Has remained in SR/SB Wants off of amiodarone
28 Case Atrial Fibrillation
29 Case Atrial Fibrillation
30 Case Atrial Fibrillation
31 Case Atrial Fibrillation
32 Questions
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