Current Guideline for AF Treatment. Young Keun On, MD, PhD, FHRS Samsung Medical Center Sungkyunkwan University School of Medicine

Transcription

1 Current Guideline for AF Treatment Young Keun On, MD, PhD, FHRS Samsung Medical Center Sungkyunkwan University School of Medicine

2 Case 1 59 year-old lady Sudden palpitation and breathlessness for 12 hours Remote onset 2 months ago Palpitation persisted for 1~2 hours HTN (-), DM (-)

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4 Echocardiography LVEF 67% LVESD/EDD 30/53 mm LA 42 mm LAVI 22 ml/m2 IVSd 10 mm, LVPWd 10 mm Normal LV and RV Valve : normal Great vessel : normal

5 What treatment strategy would you choose? 1. Rate control strategy 2. Rate control strategy with anticoagulation 3. Rhythm control strategy 4. Rhythm control strategy with anticoagulation 5. Anticoagulation only

6 Classification First detected AF Paroxysmal AF (Self- terminating) 7 days (most <24hr) Persistent AF (Not self- terminating) > 7 days Permanent AF (irreversible) Recurrent : two or more episode Longstanding persistent AF: continuous AF of greater than one-year duration

7 Diseases associated with AF Valvular Heart Disease : Rheumatic mitral disease Non-valvular HD : CAD, HTN Hyperthyroidism Pulmonary thromboembolism

8 Rhythm control for AF Pharmacologic treatment DC cardioversion RFCA (radiofrequency catheter ablation) Maze operation

9 Vaughan Williams Classification of Antiarrhythmic Drug Actions Type IA (block the sodium channel with intermediate recovery time) Disopyramide, Procainamide, Quinidine Type IB (block the sodium channel with rapid recovery time) Lidocaine, Mexiletine Type IC (block the sodium channel with slow recovery time) Flecainide, Moricizine, Propafenone Type II Beta-blockers (e.g., propranolol) Type III (prolongation of the cardiac action potential) Amiodarone, Bretylium, Dofetilide, Ibutilide, Sotalol Type IV Calcium-channel antagonists (e.g., verapamil and diltiazem)

10 Rhythm Control in AF 2014 AHA/ACC/HRS AF guideline

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12 After Medication of Propafenone 300 mg bid

13 Atrial Fibrillation The most common cardiac arrhythmia. Confers a 5-fold risk of stroke. The rate of ischemic stroke among patients with AF averages 5% per year. One of five (20%) of all strokes is attributed to AF. The risk of death from AF-related stroke is doubled.

14 Treatment strategy of AF Prevention of thromboembolism : Antithrombotic therapy Rhythm control Rate control

15 Prevention of thromboembolism in AF patients Anticoagulant Anti-platelet agents Vitamin K Antagonist Aspirin +/- Clopidogrel Warfarin NOAC

16 Stroke prevention by Warfarin vs Aspirin in AF patients Stroke prevention 39% Hart RG et al, Ann Intern Med 1999;131:492

17 Stroke and ICH by INR in AF patients Hylek EM et al, N Engl J Med 1996;335:540 INR

18 CHA 2 DS 2 VASc score and stroke rate Risk factors CHF (1) HT (1) 75 yrs old (2) DM (1) Previous stroke, TIA, Thromboembolism (2) Vascular disease (1) 65~74 yrs old (1) Annual stroke rate Female (1) Camm AJ, et al. Eur Heart J 2010

19 HAS-BLED bleeding risk score Pisters R, et al, Chest 2010 Bleeding risk score Hypertension (1) Abnormal renal function (1) Abnormal liver function (1) Stroke (1) Bleeding (1) Labile INRs (1) Elderly > 65 yrs old (1) Drugs (1) Alcohol (1) Hypertension: systolic blood pressure >160 mmhg Abnormal kidney function: the presence of chronic dialysis or renal transplantation or serum creatinine 200 mol/l. Abnormal liver function: chronic hepatic disease (e.g. cirrhosis) or bilirubin >2 x upper limit of normal in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase >3 x upper limit normal). Bleeding : previous bleeding history and/or predisposition to bleeding, e.g. bleeding diathesis, anemia, etc. Labile INRs : unstable/high INRs or poor time in therapeutic range (e.g. <60%) Drugs/alcohol use : concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse

20 CHA 2 DS 2 VASc score vs HAS-BLED score Stroke risk factors 75 yrs old (2) Previous stroke, TIA, Thromboembolism (2) CHF (1) HTN (1) DM (1) Vascular disease (1) 65~74 yrs old (1) Female (1) Bleeding risk score Elderly > 65 yrs old (1) Stroke (1) Hypertension (1) Abnormal renal function (1) Abnormal liver function (1) Bleeding (1) Labile INRs (1) Drugs (1) Alcohol (1)

21 Recommendations for Prevention of Thromboembolism in AF AHA/HRS 2014 OAC OAC/aspirin/No Tx No Tx

22 Case 1 CHA 2 DS 2 VASc score : 1 0 Female (1) ; lone AF HAS-BLED score : 0

23 What treatment strategy would you choose? 1. Rate control strategy 2. Rate control strategy with anticoagulation 3. Rhythm control strategy 4. Rhythm control strategy with anticoagulation 5. Anticoagulation only

24 Case 2 60 year-old gentleman Palpitation with chest discomfort, dizziness Drug refractory recurrent paroxysmal to persistent AF Medication Hx : propafenone, flecainide, sotalol Hypertension (+) with medication for 2 years

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26 Echocardiography Normal LV cavity size & systolic function Normal LV wall thickness No regional wall motion abnormality LVEF: 68% LVIDs/LVIDd: 27/48mm LA: 40mm LAVI: 25.7ml/m2 IVSd : 9mm LVPWd: 10mm E: 0.89m/s e`: 0.164m/s E/e`: 5.43 Ao: 27mm DT: 119.0msec

27 CHA 2 DS 2 VASc score : 1 HTN HAS-BLED score : 1 HTN

28 What treatment strategy would you choose? 1. Rate control strategy 2. Rate control strategy with anticoagulation 3. Rhythm control strategy 4. Rhythm control strategy with anticoagulation 5. Anticoagulation only

29 A conceptual model of atrial fibrillation events in relationship to underlying substrate. Both primary disease and AF-induced structural, electrical, and autonomic remodelling contribute to progression from paroxysmal to persistent AF. Nattel S, et al. Eur Heart J 2014

30 Recommendations for Thromboembolism Prevention in Cardioversion of AF/AFL Recommendations COR LOE With AF or atrial flutter for 48 h, or unknown duration, anticoagulate with warfarin for at least 3 weeks prior to and 4 weeks after cardioversion With AF or atrial flutter for 48 h or unknown duration and no anticoagulation for preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion, and then cardiovert if no LA thrombus is identified, provided anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks With AF or atrial flutter 48 h, or unknown duration, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for 3 weeks prior to and 4 weeks after cardioversion I IIa IIa B B C 2014 AHA/ACC/HRS AF guideline

31 Recurrence of Atrial Fibrillation patients after DC cardioversion

32 What treatment strategy would you choose? 1. Rate control strategy 2. Rate control strategy with anticoagulation 3. Rhythm control strategy 4. Rhythm control strategy with anticoagulation 5. Anticoagulation only

33 Recommendations for Rate Control in AF Recommendations COR LOE Control ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist for paroxysmal, persistent, or permanent AF A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of AF AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological management is inadequate and rhythm control is not achievable Lenient rate control strategy (resting heart rate <110 bpm) may be reasonable with asymptomatic patients and LV systolic function is preserved I IIa IIa IIb B B B B

34 Radiofrequency Catheter Ablation (RFCA) Radiofrequency lesion in human ventricular myocardium

35 Initiation of Atrial Fibrillation by LSPV ectopic

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37 PAC & induction of AF

38 PV Isolation by Catheter Ablation AF ablation : to eliminate AF triggers to modify the susceptible substrates

39 Three dimensional map of the LA and PV Radiofrequency lesions CT angiography

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41 Indications for catheter ablation of AF Indications for catheter ablation of AF Class Level Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication Paroxysmal : Catheter ablation is recommended Persistent : Catheter ablation is reasonable Longstanding Persistent (>12 months) : Catheter ablation may be considered Symptomatic AF prior to initiation of antiarrhythmic drug therapy with a Class 1 or 3 antiarrhythmic agent I IIa IIb A A B Paroxysmal : Catheter ablation is reasonable Persistent : Catheter ablation may be considered Longstanding Persistent : Catheter ablation may be considered IIa IIb IIb B C C 2014 AHA/ACC/HRS AF guideline

42 Korea Reimbursement criteria for AF catheter ablation by Health Insurance Review and Assessment Service 심방세동고주파절제술의보험급여기준 가. 항부정맥약제 (I or III) 중 1 가지이상을 6 주이상충분한용량으로투여한이후에도증상이조절되지않는심방세동, 약제투여전, 후심전도검사에서심방세동이증명된경우 영구형 (permanent) 심방세동에는인정하지않음 나. 항부정맥약제에대한부작용또는동결절기능부전을동반한빈맥 - 서맥증후군에서와같이약제유지가불가능한심방세동으로심전도에서확인된경우 다. 재시술은이전시술후 3 개월이경과된이후에실시, 심전도상심방세동또는심방빈맥의재발이증명된경우 보험인정기준

43 Case 3 68 year-old gentleman Frequent dizziness with palpitation No functional decline Hypertension (+), DM (+) Medication of HTN and DM

44 Tachycardia Bradycardia syndrome 1 초

45 CHA 2 DS 2 VASc score : 3 Age 68 yrs HTN DM HAS-BLED score : 2 Age 68 yrs HTN

46 What treatment strategy would you choose? 1. Rate control strategy with anticoagulation 2. Rhythm control strategy 3. Rhythm control strategy with anticoagulation 4. Anticoagulation only 5. Pacemaker

47 Points to be considered 1. Tachycardia-bradycardia? 2. Underlying Sick sinus syndrome?

48 What treatment strategy would you choose? 1. Rate control strategy with anticoagulation 2. Rhythm control strategy 3. Rhythm control strategy with anticoagulation 4. Anticoagulation only 5. Pacemaker

49 Case 4 65 year-old lady No specific symptom Detection of AF in ECG during routine health check up No functional decline Medication of beta blocker No underlying heart and other problem

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51 Echocardiography LVEF 58% LVESD/EDD 33/51 mm LA 58 mm LAVI 45 ml/m2 IVSd 10 mm, LVPWd 10 mm Normal LV and RV Valve : normal Great vessel : normal

52 What treatment strategy would you choose? 1. Rate control strategy 2. Rate control strategy with anticoagulation 3. Rhythm control strategy 4. Rhythm control strategy with anticoagulation 5. Anticoagulation only

53 Case 4 CHA 2 DS 2 VASc score : 2 65 years old (1) Female (1) HAS-BLED score : 1 65 years old (1)

54 Not an ideal candidate for AF ablation : The patient has a more advanced form of AF. There is little to be gained from a symptom perspective AF ablation should not be performed for solely curative purposes. The predominant arrhythmia mechanism shifts from a focal trigger in paroxysmal AF, to a reliance on an abnormal anatomic substrate capable of arrhythmia self-perpetuation.

55 What treatment strategy would you choose? 1. Rate control strategy 2. Rate control strategy with anticoagulation 3. Rhythm control strategy 4. Rhythm control strategy with anticoagulation 5. Anticoagulation only

56 Summary The rate of ischemic stroke among patients with AF averages 5% per year. CHA2DS2-VASc score recommended to assess stroke risk. With prior stroke, TIA, or CHA2DS2-VASc score 2, oral anticoagulants recommended. Warfarin or NOAC With nonvalvular AF and CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy. With AF or atrial flutter for 48 h, or unknown duration, anticoagulate with warfarin for at least 3 weeks prior to and 4 weeks after cardioversion. Catheter ablation of AF : symptomatic AF refractory or intolerant to antiarrhythmic medication