Practical Approaches to Atrial Fibrillation Management Answers to Your Everyday Questions

Transcription

1 Practical Approaches to Atrial Fibrillation Management Answers to Your Everyday Questions H. Mark Guo, MD, FACC, FHRS Clinical Cardiac Electrophysiology Oregon Heart & Vascular Institute

2 Disclosure SYSTEMS OF CARE SYMPOSIUM 2015 Care of Your Patient in the Era of Population Health Hongsheng Mark Guo, MD, FACC, FHRS I use free pens from all industrials. I have no other financial relationships to disclose.

3 Thursday 8 am: 63 yo man calls from MSP In AF at least since Tuesday morning Had breakfast in Indianapolis at 5:00am Flight changed to 7:00pm to continue trip Insists on not delaying trip any later Previous episode in 5/2004 (metoprolol and propafenone) Cardioversion scheduled 4:00pm

4 9:40 am 4/26/07

5 What would you do? A. Cardioverte and catch flight B. Cancel cardioversion, titrate BB, start coumadine, cardioverte after trip C. Cardioverte, start lovenox and coumadine, f/u with ACC D. Cancel cardioversion, titrate BB, start coumadine, ablation after 3-4 weeks AC E. Start NOAC, TEE, cardioverte if no clot

6 What is AF? AF is the most common sustained arrhythmia. Prevalence: 0.4% to 1% in general population, increasing with age to 12% for those > 75 yrs. Stroke rate: < 1% to > 15% annually, depending on comorbid risk factors.

7 Atrial Fibrillation Is Common

8 Atrial Fibrillation Demographics by Age U.S. population x 1000 Population with AF x ,000 20,000 U.S. population Population with atrial fibrillation , < >95 0 Age, yr Adapted from Feinberg WM. Arch Intern Med. 1995;155:

9 What is the Pathophysiology of AF? AF may be triggered by a focal source of rapid atrial electrical depolarization, often in the pulmonary veins. It is sustained by the presence of multiple reentrant wavelets or spiral wave reentrant circuits (rotors). Theories (Too Simple to be perfect) Wishes and dreams. Clueless!

10 What causes my AF? Acute and temporary causes (triggers) alcohol intake (holiday heart) surgery (particularly cardiac surgery) MI, pericarditis, myocarditis, CHF pulmonary embolism hyperthyroidism. Concurrent treatment of the underlying disorder and management of AF

11 Other Causes of AF Triggered by other arrhythmias atrial tachycardia atrial flutter Wolff-Parkinson-White (WPW) syndrome AV nodal reentrant tachycardia. Associated with chronic disorders sleep apnea hypertension obesity

12 How to establish an accurate diagnosis of AF? Symptoms maybe absent Not Reliable Irregularly irregular rhythm ECG 12-lead Ambulatory: Holter, Event monitor, ILR Device interrogation Should be distinguished from atrial flutter, multifocal atrial tachycardia reentrant SVTs, such as AV nodal reentry; sinus rhythm (SR) with multiple premature atrial complexes.

13 Are all AFs the same? Paroxysmal terminates spontaneously within 7 days of onset Persistent sustained > 7 days longstanding persistent: continuous AF > 12 months duration. Permanent Lone AF

14 Are all AFs treated in the same way? Hemodynamically unstable: Immediate cardioversion, sedate if possible Refractory, IV amiodarone, ibutilide, or procainamide. Hemodynamically stable: Cardioversion: newly diagnosed, onset within 48 hours Rate control, anticoagulation if indicated Cardioversion after 3-4 weeks anticoagulation or no clot on TEE and therapeutic anticoagulation initiated.

15 Case 72 yo woman, POD #1 (Ovarian mass removal), ECG shows AF HR bpm, BP 158/66, R 18 PMH: HTN, and CAD with LCx stented 5 yr ago What would be your most appropriate next step: A. Cardioversion B. Aspirin C. Warfarin/NOAC D. Metoprolol E. TEE

16 CASE TEE is performed. Most likely result you predicted is: A. LAA thrombus B. Spontaneous echo contrast (smoke) in LA C. Clear LAA D. Annual stroke risk is 1-2% E. Annual stroke risk is 3-5% F. Annual stroke risk is 5-9%

17 CHA 2 DS 2 -VASc Risk factor score C Congestive heart failure/lv dysfunction 1 H Hypertension 1 A2 Age 75y 2 D Diabetes mellitus 1 S2 Stroke/TIA/TE 2 V Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1 A Age 65-74y 1 Sc Sex category (ie female gender) 1 Maximum Score 9 maximum score is 9 since age may contrubute 0, 1, or 2 points Lip GY, et al., Chest 137, , 2010

18 CHA 2 DS 2 -VASc overall event rates %/year 6 Stroke and systemic embolism CHA 2 DS 2 -VASc No of patients

19 Marine JE. JAMA. 2007; 298(23):

20 Cryoballoon

21 Atrial Fibrillation Ablation: Success & Repeat Procedures 50 70% success with a single procedure Up to 50% will require a second procedure to achieve success 50% will have early recurrence within the first couple days to weeks 50% of these will resolve within few weeks and still have success

22 Atrial Fibrillation Ablation: Long Term Outcome Free of antiarrhythmic drugs and free of arrhythmia symptoms at 6 months Paroxysmal 70 to 90% Persistent (lasts > 7 days, up to 1 year) 60 to 80% Long standing persistent (> 1 year) 50 to 70%

23 Atrial Fibrillation Ablation: What are the risks? Major: (overall risk < 1%) Stroke (0.2%) Heart attack (< 0.02%) Atrial-esophageal fistula (rare 0.02%) Death (0.1%) Intermediate: Pulmonary vein narrowing or stenosis (0.3%) Bleeding around the heart or tamponade (1.0%) Diaphragm paralysis (0.2%) Need for a pacemaker (rare - < 0.02%) Minor: Groin site bleeding or hematoma (1-3%) Infection (0.01%) *Second Worldwide Survey on the Efficacy and Safety of Catheter Ablation for Atrial Fibrillation

24 Atrioesophageal Fistula

25 Catheter Ablation: How Is A Cure Delivered? Conventional Better understanding of mechanism Fixed circuits or foci Target: substrate Atrial flutter AVNRT WPW Focal atrial tachycardia VT AF Ablation Mechanism? Microreentry Multiple wavefronts No fixed circuit Triggers Target(s): Triggers? Drivers? Substrate? Autonomic nerves?

26 What Is EP? Exquisiteness Elegance Delicacy 高雅 精巧 精致优雅 Precision Perfection Cure Satisfaction 精确 完美

27 What Is EP? Massiveness 粗糙 Nastiness 邋遢 Reckless 鲁莽 Excessiveness 多余 Destructiveness 毁坏 Exquisiteness Elegance Delicacy Precision Perfection Cure Satisfaction Deviating

28 When to offer a therapy as first-line? Safety Effectiveness Need from patient

29 AF Ablation Summary AF ablation is an AF ablation, still. There are many uncertainties. More data is needed. It is still too early to be offered to most patients as a first-line therapy. Catheter ablation might be the right answer for some patients.

30 Priority of Care Rate Control Anticoagualtion Rhythm Control

31 2/15/06, ER: 58 yo Man, Day Before EPS

32 Before (12/23/05 08:47:00) After (02/16/06 15:50:55)

33 What s New in 2015? Stroke risk assessment: CHA 2 DS 2 -VASc New oral anticoagulants: Dabigatran Rivaroxaban Apixaban Edoxaban Ablation: targeting substrates Digoxin: associated with worse outcome

34 Stroke Prevention in 2015

35 Digoxin is associated with bad outcomes

36 Sinus Rhythm, Not AAD Use, Is Associated With Improved Survival The AFFIRM Investigators. Circulation. 2004;109:

37 AF Ablation in 2015 Targeting Substrates

38 Atrial Fibrosis Is Associated With AF Recurrence

39 Summary AF is common, with different clinical presentations. AF is a complicated arrhythmia and our understanding regarding the exact mechanism remains limited. Catheter ablation, although based on imperfect theory, may help selected patients. AF is a manageable arrhythmia, and options are available for all patients to minimize risks for complications and to improve quality of life.

40 References Questions? GUO