Hypertension and Atrial Fibrillation in 2017

Transcription

1 Boma Inn, Eldoret, 24th 25thFebruary 2017 Hypertension and Atrial Fibrillation in 2017 Dr Mzee Ngunga Consultant Cardiologist Aga Khan University Hospital, Nairobi

2 Objectives 1. Understand the relationship between hypertension and atrial fibrillation 2. How to diagnose atrial fibrillation 3. Know the tests required in the hypertensive patient with suspected atrial fibrillation 4. Understand the principles of treatment of atrial fibrillation 5. How do we prevent Atrial Fibrillation 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

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6 Statement of Need My greatest challenge as a health care provider in the management of patients with hypertension is 6

7 A. Failure to control blood pressure B. Fear of side effects C. Uncertainty about the dose of drug D. Inability to predict long term outcome E. Patient cannot afford medication F. Uncertainity about combination therapy G. Other 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

8 Hypertension as a Risk Factor Hypertension is a significant risk factor for: cerebrovascular disease coronary artery disease congestive heart failure renal failure peripheral vascular disease dementia atrial fibrillation 8

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10 Hypertension in A.fib trials Kenya Cardiac Society. Boma Inn Eldoret /1/2017

11 Stroke 1/6 of strokes related to A.fib

12 Question #1 A 46 year old white male patient is in for an annual physical exam. What is his lifetime risk of developing AF? 1. 1% 2. 5% 3. 10% 4. 25%

13 Incidence of AF Lifetime Risk for AF at Selected Index Ages by Sex Index Age, yrs Men Women % ( ) 23.0% ( ) % ( ) 23.2% ( ) % ( ) 23.4% ( ) % ( ) 23.0% ( ) % ( ) 21.6% ( ) 1 in 4 Men & women >40 Years will develop AF Lifetime risk if currently free of AF Lloyd Jones DM, et al. Circulation Aug 31;110(9): Pub Med PMID:

14 Pathogenesis: Principal atrial fibrillation (AF) maintaining mechanisms. Yu-ki Iwasaki et al. Circulation. 2011;124: Copyright American Heart Association, Inc. All rights reserved.

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16 Dynamic interactions between atrial and ventricular function during atrial fibrillation Yu-ki Iwasaki et al. Circulation. 2011;124: Copyright American Heart Association, Inc. All rights reserved.

17 Case 1 67 year old female Hypertension 5 years Meds: HCTZ 25mg od, Enalapril 10mg od Seen with exertional dyspnea, NYHA class II No other symptoms of HF Exam: BMI 37. BP 156/99mmHG. HR 128bpm Exam: Nil significant in CVS, CNS 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

18 Progression from Hypertension to Heart Failure Obesity Diabetes LVH Diastolic dysfunction Hypertension HF Death Smoking Dyslipidaemia Diabetes MI Systolic dysfunction Normal LV structure and function LV remodelling Subclinical LV dysfunction Overt heart failure Time: decades Time: months

19 Investigations Blood: TBC, renal profile, lipids? FBG?TSH Urinalysis. Other: ECG Echo 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

20 What are the benefits of performing in ECG in this patient? Document the patient s heart rhythm Assessing for LVH or atrial abnormality or previous MI Measure baseline QT interval that may be affected by pharmacologic therapy 20

21 The ECG Flutter waves 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

22 What are the Risk Factors for developing A.fib in patients with hypertension? 1. Age 2. Diabetes 3. LVH on ECG, echo 4. Systolic/Diastolic dysfunction 5. Left atrial enlargement 6. Valvular Heart disease 7. Obstructive sleep apnoea 8. Coronary artery disease 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

23 Review the History Alcohol best evidence is for those drinking 5+ per day Thyroid Disease Sleep apnoea Family history 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

24 Role of Echocardiography Measure size of the LA Assess LV systolic function Assess for ventricular function in including diastolic dysfunction Assess for valvular disease Assess for LVH Also can estimate the PA pressure (right ventricular systolic Pressure) 24

25 Management Acute (<48 hrs) Vs Chronic Stable Vs Unstable patient Rate control Vs Rhythm control Anticoagulation 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

26 Indications for Urgent Direct Cardioversion Hemodynamic Instability: Patient with decompensated heart failure Active ischemia: if symptomatic with angina or evidence of ischemia/infarction on EKG Evidence of organ hypoperfusion (altered mental status, cold clammy skin, acute kidney injury)

27 Urgent Cardioversion Electrical Cardioversion: sedate patient and place setting on direct synchronization then shock Initial shock setting of 100J 200J 300J 360J until sinus rhythm returns Make sure you perform direct cardioversion with R wave synchronization to prevent an R on T phenomenon which can lead to V fib Restoration of normal sinus rhythm takes precedence over need for protection from thromboembolic risk Recommend cardiology consult at this time Give stat dose of enoxaparin 1mg/kg sc at the time of cardioversion

28 If Patient is Hemodynamically Stable Goal is ventricular rate control (<100 bpm) and anticoagulation Resting HR goal should be bpm in symptomatic patient Roughly 50% of patients with new onset AF will spontaneously convert to NSR spontaneously within 48 hours of onset Rate control or Rhythm control? AFFIRM trial and RACE trial No survival advantage in terms of stroke prevention rhythm control over rate control rate control Rate control agents Beta blockers (caution in patients with reactive airway disease) Calcium Channel Blockers (Contraindicated in HF) Digoxin Amiodarone (for patients intolerant or unresponsive to other agents)

29 Rate Control Agents Drug Classes Drug Loading Dose Maintenance Dose Calcium Channel Blockers (nondihydropyridine) Beta Blockers initial DOC Other Diltiazem 10 mg IV over 2 minutes Can repeat up to 20 mg IV Metoprolol Digoxin 5 mg IVP q5min x3 doses 0.5 mg IV loading dose 0.25mg IV in 6 hrs 0.25mg IV 6 hrs after Other Amiodarone 150 mg IV/10 min 1mg/minx 6 hrs 0.5 mg/min x 18hrs 30 mg PO q6 hrs (can transition to long acting mg daily) Can use 10 mg IV q6 hrs prn 25 mg PO BID, can uptitrate to 100mg PO BID mg PO QD mg PO QD

30 CHA 2 DS 2 VASc 2009 Birmingham Schema Expressed as a Point-Based Scoring System Risk Factor Score Congestive heart failure/lv dysfunction 1 Hypertension 1 Age 75 y 2 Diabetes mellitus 1 Stroke/TIA/TE 2 Vascular disease (prior 1 myocardial infarction, peripheral artery disease, or aortic plaque) Age y 1 Sex category (i.e. female gender) 1 LV = left ventricular; TE = thromboembolism Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Chest Feb;137(2): Pub Med PMID:

31 CHA 2 DS 2 VASc Stroke or Other TE at One Year CHA 2 DS 2 VASc Score # #TE Events TE Rate During 1 yr (95% CI) TE Rate During 1 yr, Adjusted for Aspirin RX % (0 0) 0% % ( ) 0.7% % ( ) 1.9% % ( ) 4.7% % ( ) 2.3% % ( ) 3.9% % ( ) 4.5% % ( ) 10.1% % ( ) 14.2% % ( ) 100% Total 1, P Value for trend Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Chest Feb;137(2): Pub Med PMID:

32 New CCS Algorithm: 2014

33 Vitamin K antagonists (VKAs) Vs NOACs) for thromboembolic prevention in patients with non-valvular AF Largely similar efficacy (BUT Dabigatran 150mg BID) BUT NOCS Predictable effect without need for monitoring Fewer food and drug interactions More predictable half-life/elimination Improved efficacy/safety ratio 1

34 NOACs approved or for prevention of systemic embolism or stroke in patients with non-valvular AF Dabigatran Apixaban Edoxaban * Rivaroxaban Action Direct thrombin inhibitor Activated factor Xa (FXa) inhibitor Activated factor Xa (FXa) inhibitor Activated factor Xa (FXa) inhibitor Dose Phase III clinical trial 60 mg QD 150 mg BID 5 mg BID 20 mg QD 30 mg QD 110 mg BID 2.5 mg BID 15 mg QD 15 mg QD ARISTOTLE 2 RE-LY 1 ENGAGE-AF 4 ROCKET-AF 5 AVERROES 3 * not yet approved by EMA 1. Connolly et al, N Engl J Med 2009; 361: Ruff et al, Am Heart J 2010; 160: Granger et al, N Engl J Med 2011; 365: Patel et al, N Engl J Med 2011;365: Connolly et al, N Engl J Med 2011; 364:

35 Prevention of A.fib? Is there evidence that treating hypertension reduces likelihood of A.fib? 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

36 Meta Analysis Healey et al: 11 randomized controlled clinical trials by. renin angiotensin system (RAS) blockers significantly reduced the relative risk (RR) of new onset atrial fibrillation by 28% (15 40%) benefit was limited to patients with LVH Kalus et al. (ACEI) or (ARB) was associated with an average 49% (35 72%) RR in new onset atrial fibrillation, a 53% (24 92%) lower failure rate of electrical cardioversion of atrial fibrillation 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

37 6 LIFE: New Onset Atrial Fibrillation: Losartan Proportion of patients with first event % 7 HR: 0.67 [95% CI: ], p<0.001 Adjusted HR: 0.67 [95% CI: ], p< Atenolol group Losartan group Time (months) Wachtell et al J Am Coll Cardiol 2005

38 Sub Group Analysis VALUE trial, the use of valsartan (vs. amlodipine) was associated with a 16% reduction (P < ) in the incidence of at least one documented occurrence of new onset atrial fibrillation and reduced the incidence of persistent atrial fibrillation by 32% 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

39 The GISSI AF Investigators Valsartan for Prevention of Recurrent Atrial Fibrillation In a randomized trial, 1442 patients with a history of atrial fibrillation were assigned to receive either valsartan, an angiotensin II-receptor blocker, or placebo Antiarrhythmic therapy was administered according to the treating physician's preference At 1 year, there was no difference between the groups in the rate of either a first recurrence or multiple recurrences of atrial fibrillation 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

40 ACTIVE I invsetigators Irbesartan for prevention of A.fib In patients with atrial fibrillation, angiotensin-receptor blockade with irbesartan did not reduce the risk of cardiovascular events. The results of this study do not provide support for the use of irbesartan to improve outcomes in patients with atrial fibrillation 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017

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42 Questions?? 3/1/2017 Kenya Cardiac Society. Boma Inn Eldoret 2017