Atrial fibrillation workshop: rate- versus rhythm-control

Transcription

1 Atrial fibrillation workshop: rate- versus rhythm-control Rocky Mountain Internal Medicine Conference Nov, 2011 Dr F. Russell Quinn Cardiac Electrophysiologist, Foothills Medical Centre, Calgary

2 Disclosures Honoraria Boehringer Ingelheim Sanofi Aventis Medtronic

3 Outline Clinical case Factors influencing decision between ratecontrol & rhythm-control approaches Underlying principles of management Tips from the CCS guidelines

4 Clinical case WB 64-yr-old male Background: Bipolar affective disorder diagnosed age 25 (well controlled) Dyslipidaemia Overweight No hypertension, diabetes, CAD, CVA Since 1994, intermittent episodes of palpitation Associated breathlessness & exercise limitation

5 Holter

6 Holter

7 Holter Multiple episodes few sec up to 2 min

8 Management? Look for underlying conditions BP, structural heart disease, thyroid dysfunction, alcohol, OSAS, etc Appropriate antithrombotic therapy CHADS 2 =0 CHA 2 DS 2 -VaSC=0 Management of dysrhythmia

9 Factors to consider Favours rhythm-control Paroxysmal AF Newly-detected AF Symptomatic in AF Age<65 No hypertension CHF or angina exacerbated by AF Not previously failed AADs Favours rate-control Persistent AF (Permanent AF) Minimal symptoms Age>65 Hypertension No CHF Previously failed AADs CCS AF Guidelines 2010

10 Factors to consider Favours rhythm-control Paroxysmal AF Newly-detected AF Symptomatic in AF Age<65 No hypertension CHF or angina exacerbated by AF Not previously failed AADs Favours rate-control Persistent AF (Permanent AF) Minimal symptoms Age>65 Hypertension No CHF Previously failed AADs CCS AF Guidelines 2010

11 Clinical case progress Started on ASA & propafenone Reasonable symptom-control

12 Nov, 2007 Admitted with presyncopal episode Possibilities? 1. AF with rapid ventricular response 2. Bradycardia 3. Proarrhythmic effect of propafenone 4. Another cause

13 Telemetry monitoring 6.8 s 6.3 s Dual chamber pacemaker implanted Discharged on ASA, propafenone 150 mg tid & metoprolol 6.25 mg bid

14 Clinical case progress Symptoms reasonably controlled 2008 episode of syncope Possibilities? 1. AF with rapid ventricular response 2. Bradycardia 3. Proarrhythmic effect of propafenone 4. Another cause

15 Pacemaker interrogation

16 Pacemaker interrogation Numerous ventricular high-rate events, one corresponding with syncope Still intermittently symptomatic from AF episodes Options? 1. Increase dose of propafenone 2. Add rate-control agent 3. Switch antiarrhythmic drug Amiodarone 4. AF ablation 5. Ablate his AV node

17 Clinical case progress Good symptom-control Short infrequent atrial high-rate events on PPM

18 Clinical case progress April 2009 worsening palpitations Amiodarone increased to 300 mg od Felt no better

19 Clinical case progress Now what? 1. Stop amio & switch to rate-control approach 2. Add rate-control agent 3. AF ablation 4. Check blood amiodarone levels 5. Check other bloods Additional symptoms: Weight loss 15 lb Reduced energy, difficulty getting out of chair / bed Lightheadedness Tremor

20 Bloods! TSH <0.01mU/L ( ) ft4 >100 pmol/l (8-22) tt3 4.2 nmol/l ( ) Diagnosed as Type II amiodarone-induced thyroiditis (AIT) Type I = enhanced hormone production (preexisting multinodular goitre / latent Graves disease) Type II = destructive thyroiditis with increased hormone release

21 Management Stopped amiodarone Started on methimazole & prednisone What about his AF? 1. Switch to rate-control strategy 2. Persist with rhythm-control strategy Metoprolol + digoxin added Referral made for consideration of AF ablation

22 Follow-up Amiodarone 200 mg 300 mg Symptoms improved

23 Progress CPAP Symptoms remained settled No indication for ablation Also treated for severe OSAS

24 Tips from the recent AF guidelines

25 Rate- or rhythm-control? No right or wrong answer Often, the two are simultaneous: Rhythm control requires good rate control when patient goes back into AF

26 Rate-control goals Goals of ventricular rate control should be to improve symptoms and quality of life which are attributable to excessive ventricular rates. (Strong recommendation, low quality evidence) CCS AF Guidelines 2010

27 What is the target for heart rate? RACE II Trial - No difference in outcome between: Strict rate control (< 80 bpm at rest, < 110 bpm with exercise), and Lenient rate control (< 110 bpm at rest) However, actual HR in both groups were 75 and 86 respectively Few patients had HR > 100 bpm NEJM. 2010;362:

28 What is the target for heart rate? CCS AF Guidelines 2010 Aim for resting heart rate <100 bpm

29 CCS AF Guidelines 2010

30 Rhythm-control goals Goals of rhythm control therapy should be to improve patient symptoms and clinical outcomes, and that these do not necessarily imply the elimination of all AF. (Strong recommendation, moderate quality evidence) CCS AF Guidelines 2010

31 Rhythm-control tenets Strategy of rhythm control has never been shown to reduce mortality compared to rate control (AFFIRM, RACE, PIAF trials, AF CHF) Therefore, goals of rhythm control should focus on improving quality of life Rhythm control does not necessitate elimination of all AF

32 Rhythm-control tenets Rhythm control does not replace anticoagulation No evidence that AF reduction via antiarrhythmic therapy reduces the risk of stroke/thromboembolism Patients must continue on appropriate anticoagulation according to their individual embolic risk (CHADS 2 score)

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35 Longitudinal pattern of AF Strategies may need to change over time

36 Longitudinal pattern of AF

37 Questions?