Rate Control: What is the Goal and How to Achieve It? Steve Greer, MD, FHRS, FACC BHHI Primary Care Symposium February 28, 2014

Transcription

1 Rate Control: What is the Goal and How to Achieve It? Steve Greer, MD, FHRS, FACC BHHI Primary Care Symposium February 28, 2014

2 Financial Disclosures Boerhinger Ingelheim Research Support Boston Scientific Research Support Chelsea Therapeutics Research Support National Institutes of Health Research Support St Jude Medical Research Support

3 Treatment Philosophy for AF Two approaches to treatment of AF Rate control Rhythm control Each has its strengths and weaknesses Which one is the best option?

4 AF Treatment Options Rhythm Control Presumed Advantages Possibly fewer symptoms Better exercise tolerance Lower risk of stroke Possible avoidance of anticoagulation Better quality of life Possibly improved survival

5 AF Treatment Options Rate Control Presumed Advantages Simplify therapy Avoid drugs with more severe side effects

6 AFFIRM 4060 patients in trial Mean follow-up: 3.5 years (Max: 6 years) Randomized to Rate Control and Rhythm Control Rate control: N=2027 Rhythm control: N=2033

7 AFFIRM Results Hazard Ratios for Death in Prespecified Subgroups. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med 2002;347:

8 AFFIRM Mortality Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med 2002;347:

9 Rate Control of AF Employed regardless of long-term choice Potential options Beta blockers Calcium channel blockers Digoxin Others

10 Beta Blockers Question 1: How many beta blockers are FDA approved for the treatment of atrial fibrillation?

11 Beta Blockers Question 1: How many beta blockers are FDA approved for the treatment of atrial fibrillation? Answer: Two (propranolol and sotalol)

12 Beta Blockers Beta receptors vary depending on organ Beta 1: Heart Beta 2: Lung Beta 3: Vascular walls

13 Beta Blockers Preference for beta 1 selective agents Atenolol (PO) Metoprolol (PO or IV) Acebutolol (PO) Bisoprolol (PO) Esmolol (IV) Selectivity is lost with large doses

14 Calcium Channel Blockers Only non-dihydropyridine drugs are of benefit Diltiazem (PO or IV) Verapamil (PO or IV)

15 Other Drugs Other potential agents for rate control Digoxin (PO or IV) Clonidine (PO or topical) Amiodarone (PO or IV) Digoxin rarely effective as primary agent except when AV conduction disease present Use limited to adjunctive therapy

16 Approach to Rate Control Class I Indications Beta blockers Verapamil or diltiazem Digoxin Effective in control of resting HR Suitable for patients with CHF and sedentary individual IV beta blocker, calcium blocker, digoxin or amiodarone to control HR with CHF and rapid ventricular rates

17 Approach to Rate Control Class II Indications Combination of digoxin and either a beta blocker or calcium blocker to control rate at rest and during exercise AVN or accessory pathway ablation may be considered when medical therapy is insufficient or associated with side effects

18 Approach to Rate Control Class III indications Digoxin should not be used as sole agent for rate control AVN ablation is not first line therapy for rate control Digoxin and calcium blocker for pre-excited AF

19 Rate Control J Am Coll Cardiol. 1999;33(2): doi: /s (98)

20 Assessment of Rate Control Target HR: Less than 80 bpm at rest Less than 110 bpm with modest exercise Methods Resting HR 6 minutes hall walk Treadmill Holter

21 Why is Rate Control Important?

22 Ventricular Rate Control Strict Rate Control At rest: bpm Moderate exercise (TM, hall walk): 115 bpm If symptoms noted during exercise, heart rate control should be assessed during exercise Lenient Rate Control (RACE II trial) Resting HR <110 bpm Possible effects of elevated HR on LV function not studied

23 Effects of Rate Control Van Gelder IC et al. N Engl J Med 2010;362:

24 Non-Pharmacologic Rate Control

25 Questions?