Στυλιανός Τζέης MD, PhD, FESC

Transcription

1 Βραχειάς δια ρκειας ριπε ςυπερκοιλιακη ς ταχυαρρυθμιάς στο Holter ρυθμου η στις συσκευε ςδιαχει ρισης του καρδιακου ρυθμου. Θα χορηγη σουμε αντιθρομβωτικη αγωγη ; Στυλιανός Τζέης MD, PhD, FESC Επιμελητής Καρδιολογικής Κλινικής, Νοσοκομείο Ερρίκος Ντυνάν

2 Challenging situations in AF diagnosis and detection

3 Is it atrial fibrillation? 29 complexes Duration: 9.8 sec

4 What is the minimum duration of an arrhythmia displaying ECG characteristics of AF on a rhythm strip to be diagnosed as atrial fibrillation?.. at least 30 sec on a rhythm strip

5 Europace 2010;12:17-23

6 Clinical scenario Subclinical atrial tachyarrhythmia in PM/ICD recipients without history of atrial fibrillation

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8 Hypothesis: Is there a relationship between TE risk and AT/AF burden detected by devices capable of continuous heart rhythm monitoring. Study population: Prospective enrolment 2486 device recipients CHADS score 1 History of AF or device-detected AT/AF during the first year of FU ΑΤ/ΑF burden: maximum daily duration of AT/AF on any given day during the preceding 30-days Circ Arrhythmia Electrophysiol. 2009;2:

9 AT/AF burden groups: zero, low and high Group A: zero burden Group B: low burden (< 5.5 hours duration) Group C: high burden (> 5.5 hours duration) Clinical implications A.AT/AF AT/AF burden 5.5 hours on any day in the most recent 30 days is associated with an approximate doubling of the risk of thromboembolic events compared with zero AT/AF burden, after controlling for clinical stroke risk factors and antithrombotic use. Circ Arrhythmia Electrophysiol. 2009;2:

10 Patient population: 2580 pacemaker or ICD recipients, aged 65 yrs, with hypertension, without history of atrial fibrillation.

11 > 190 bpm for > 6 min

12 Device-detected subclinical atrial tachyarrhythmias (>6 min, >190 bpm) are present in 36% of pacemaker patients with hypertension, but no prior AF over 2.8 years mean follow-u p. are associated with a 5.5-fold increased risk of clinical atrial tachyarrhythmia

13 Device-detected subclinical atrial tachyarrhythmias (>6 min, >190 bpm) are associated with a 2.5-fold increased risk of ischemic stroke or embolism. increase the absolute risk of stroke or embolism to 2.1% per year in patients with CHADS 2 score 2 to 3.78% per year in patients with CHADS 2 score > 2

14 Device-detected atrial tachyarrhythmias (>6 min, >190 bpm) increase the absolute risk of stroke or embolism to 2.1% per year in patients with CHADS 2 score 2. Should we anticoagulate those patients?

15 Retrospective, single-centre analysis, 445 device recipients In patients with pacemaker-detected AF (atrial high rate episodes AHRE), anticoagulants were used more frequently among patients who also had clinical AF compared with those without (p < 0.001).

16 Reasons NOT to anticoagulate 1. No temporal relationship between AHRE and stroke

17 No temporal association between device-detected detected AHRE and stroke Subgroup of 40 (1.6%) patients enrolled in TRENDS who experienced CVE/SE. AT/AF was detected prior to CVE/SE in 20 (50%) of 40 patients. The last episode of AT/AF in these 14 patients was 168 ±199 days (range days) before CVE/SE.

18 Only 8% of patients had subclinical atrial fibrillation detected within 30 days before stroke or systemic embolism Only 1 patient (2%) was experiencing SCAF at the time of the stroke Circulation. 2014;129:

19 Reasons NOT to anticoagulate 2. False positive AHRE episodes

20 Heart Rhythm Aug;9(8): The distribution of atrial high-rate episodes after adjudication Appropriate episodes (82.7%), RNRVAS (13.9%), farfield R-wave oversensing (1.3%), noise (1.2%), and other (0.9%) are displayed in shades of gray. RNRVAS = repetitive non reentrant ventriculoatrial synchrony.

21 Europace Jul;16(7):1091

22 Reasons NOT to anticoagulate 3. AHRE episodes: simply a risk marker for other diseases e.g. hypertension that predispose a patient to an increased risk of stroke? Perhaps one more risk factor to add to CHA 2 DS 2 -VASc score?

23 ESC ACC GUIDELINES: no specific recommendations Practical suggestions Interrogate all episodes: true AF episodes? Parameters to consider: AF duration, total daily duration, CHADSVASC score

24 ESC ACC GUIDELINES: no specific recommendations CHADSVASC = 0, or 1 in females: Never anticoagulate CHADSVASC 1, episode duration > 6 min, total daily duration > 5.5h Definitely anticoagulate CHADSVASC 1, episode duration > 30 sec: Yes anticoagulate (The higher the CHADSVASC the more definite the need) CHADSVASC = 1, episode duration < 30 sec: Rather not anticoagulate Always: INDIVIDUALIZE!!!!