Conversion Of Acute Atrial Fibrillation With Propafenone Or Vernakalant

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1 AF: Cardioversion & Anti-Thrombotic Issues Conversion Of Acute Atrial Fibrillation With Propafenone Or Vernakalant D. Conde, J.P. Costabel, M. Aragon, M.F. Lambardi, M. Trivi, A. Giniger Emergency Department, Cardiovascular Institute of Buenos Aires, Buenos Aires, Argentina Introduction: Intravenous vernakalant has effectively converted acute Atrial Fibrillation (AF) to Sinus Rhythm (SR) and demonstrated efficacy superior to placebo and amiodarone. The objective of this study is compare the efficacy and safety of intravenous vernakalant and oral loading dose of propafenone for conversion of acute (AF). Methods: A total of 40 adult patients with acute AF (less than 48 hours duration) without heart disease were enrolled. Patients received, intravenous vernakalant (n=20), or an oral loading dose of propafenone with 600 mg (n=20). Efficacy end point was the time to conversion from acute AF to SR. Results: The mean time to conversion from AF to SR in patients who received propafenone was 166 ( ) minutes and 9 (6-18) minutes in patients who received vernakalant (p < ). The mean hospitalization time was 416 ( ) minutes in propafenone group and 238 ( ) minutes in vernakalant group (p < ). There were no serious adverse events. Conclusion: Vernakalant demonstrated a shorter time to conversion from AF to SR than propafenone and a shorter hospitalization time. Both were safe and well tolerate. Table 1 Demographic and Baseline Characteristics Baseline characteristics Propfenone Vernakalant Male - % Age yrs mean SD 62 (54-66) 67 (56-69,5) Diabetes - % 5 5,8 Hypertesion - % Smokers - % Previous AF % Previous Ablation of AF % 5 11 Beta-blockers % Amiodarone % 0 10 Propafenone/Flecainide % 5 0 Anticoagulation % 0 0

2 Pharmacological Management Of Recent-Onset Atrial Fibrillation In Acute Setting: An Open-Label Cohort Study A. Bonora *, F. Beltrame, G. Taioli #, G. Zerman*, P. Castiglioni *, R. Codogni #, E. Sanzone *, E. Franchi, D. Girelli #, C. Pistorelli * *Department of Emergency and Intensive Therapy Department of Cardiology # Department of Internal Medicine, School of Emergency Medicine University of Verona, Verona, Italy Aim: To compare efficacy and safety of amiodarone, propafenone and flecainide in treating recent-onset AF in acute setting. Methods: Out of patients observed from January 2009 to December 2011 for recent-onset AF in our Emergency Department, we considered only those with first attempt at cardioversion and without clinical conditions forcing pharmacological strategy. Depending on physician s choice, patients received a bolus of amiodarone 4 mg/kg or propafenone 2 mg/kg or flecainide 2 mg/kg,. Results: A number of 302 patients with homogenous baseline characteristics (157 males, 145 females, mean age 60.4 years) were considered in this study. At the end of 12-hours observation period, conversion to sinus rhythm was achieved in 51.5% of patients in amiodarone, 76.2% in propafenone and 89.1% in flecainide group (flecainide and propafenone vs amiodarone p<0.0001). Median time to cardioversion was significantly shorter in flecainide and propafenone than in amiodarone group (p<0.0001). We reported an overall very low incidence of adverse events. Need for hospitalization resulted higher in amiodarone group (p<0.001). Conclusions: Flecainide and propafenone resulted more effective and as safe than amiodarone in acute management of AF.

3 Pharmacological Management Of Recent-Onset Atrial Fibrillation In Acute Setting: An Open-Label Cohort Study A. Bonora *, F. Beltrame, G. Taioli #, G. Zerman*, P. Castiglioni *, R. Codogni #, E. Sanzone *, E. Franchi, D. Girelli #, C. Pistorelli * *Department of Emergency and Intensive Therapy Department of Cardiology # Department of Internal Medicine, School of Emergency Medicine University of Verona, Verona, Italy Aim: To compare efficacy and safety of amiodarone, propafenone and flecainide in treating recent-onset AF in acute setting. Methods: Out of patients observed from January 2009 to December 2011 for recent-onset AF in our Emergency Department, we considered only those with first attempt at cardioversion and without clinical conditions forcing pharmacological strategy. Depending on physician s choice, patients received a bolus of amiodarone 4 mg/kg or propafenone 2 mg/kg or flecainide 2 mg/kg,. Results: A number of 302 patients with homogenous baseline characteristics (157 males, 145 females, mean age 60.4 years) were considered in this study. At the end of 12-hours observation period, conversion to sinus rhythm was achieved in 51.5% of patients in amiodarone, 76.2% in propafenone and 89.1% in flecainide group (flecainide and propafenone vs amiodarone p<0.0001). Median time to cardioversion was significantly shorter in flecainide and propafenone than in amiodarone group (p<0.0001). We reported an overall very low incidence of adverse events. Need for hospitalization resulted higher in amiodarone group (p<0.001). Conclusions: Flecainide and propafenone resulted more effective and as safe than amiodarone in acute management of AF.

4 Clinical Characteristics And Outcomes Of Patients With Non- Valvular Atrial Fibrillation Who Undergo Multiple Direct-Current Cardioversion Procedures A. García-Fernández, F. Marín-Ortuño, J.G. Martínez-Martínez, A, Ibáñez-Criado, J.L. Ibáñez-Criado, V. Roldán- Schilling, M. Valdés,, F. Sogorb-Garri Arrhtyhmia Unit, Cardiology Department, general Hospital of Alicante, Spain. Cardiology Department, Hospital Virgen de la Arrixaca, Murcia, Spain. Haematology Department, Hospital Morales Meseguer, Murcia, Spain Introduction: Although immediate success rates of DC cardioversion (CV) in NVAF patients are known to be very high, recurrence is the usual pattern, being many patients submitted to multiple procedures. We aimed to determine if clinical profile and long-term outcome are different in these patients. Methods: We studied 326 patients who underwent 456 DC CV (form January 2008 to August 2011). We compared clinical characteristics, thromboembolic risk (CHA 2 -VASc score), long-term maintenance of sinus rhythm and event rates (embolism, major bleeding and death) in both two groups of patients: Group 1 ( 2 CV) and Group 2 ( 3 CV). Results: Patients in Group 2 (N=21) were younger (61.1±12.0 vs 66.9±10.9 years, p=0.02) and had less thromboembolic risk (CHA2DS2- VASc: 2.14±1.52 vs 2.86±1.59, p=0.04) than patients in Group 1 (N=305). During a median follow up of 740 [ ] days, the proportion of patients in sinus rhythm and the event rates were similar in both groups (23.4% vs 35.0%, p:0.57). Conclusions: AF patients who undergo multiple CV procedures tend to be younger and have less thromboembolic risk. The proportion of maintenance of sinus rhythm and the rate of events are similar in both groups. Table 1 Baseline characteristics of patients in Group 1 ( 2 CV) and in Group 2 ( 3 CV). Patient Group 1 (N=305) Group 2 (N=21) p Male (%) 210 (68.9) 18 (87.5) 0.1 Age (years) 66.9± ± Idiopathic AF(%) 27 (9) 3 (14.3) 0.41 Hypertension (%) 246 (80.9) 15 (71.4) 0.53 Diabetes (%) 83 (27.4) 5(23.8) 0.72 Heart failure (%) 78 (25.7) 7 (33.3) 0.72 Previous embolism (%) 19 (6.3) 1 (4.8) 0.78 Heart disease (%) 121 (40.2) 7 (33) 0.53 CHA 2 -VASc score 2.86± ± Table 2 Proportion of patients in sinus rhythm at end of follow-up and event rate. Patient Group 1 (N=305) Group 2 (N=21) p Sinus rhythm (%) 71 (23.4) 7 (35.0) 0.57 Embolic events (%) 18(6) 3 (15) 0.11 Major bleeding (%) 9 (3) 0 (0) 0.43 Death (%) 19 (6.3) 0 (0) 0.24

5 Utility Of The CHADS2 And CHA2DS2-Vasc Scores To Predict Embolic Risk After Direct-Current Cardioversion In Non-Valvular Atrial Fibrillation A. García-Fernández, F. Marín-Ortuño, V. Roldán-Schilling, J.G. Martínez-Martínez, A, Ibáñez-Criado, J.L. Ibáñez- Criado,, M. Valdés,, F. Sogorb-Garri Arrhtyhmia Unit, Cardiology Department, general Hospital of Alicante, Spain. Cardiology Department, Hospital Virgen de la Arrixaca, Murcia, Spain. Haematology Department, Hospital Morales Meseguer, Murcia, Spain Introduction: The usefulness of the CHA and CHA 2 -VASc scores to predict thromboembolism in non-valvular AF has been well validated, but their predictive value after electrical cardioversion has not been thoroughly investigated. The aim of this study is to analyze the role of both scores to predict thromboembolic risk in a real-world cohort of patients with AF who undergo DC cardioversion. Methods: T We included 326 consecutive patients who underwent 456 programmed cardioversions between January 2008 and August We calculated the association between both scales and the development of all embolic events during follow-up. Results: TDuring a median follow-up of 740 ( ) days, there were 20 embolic events (4.38%), (2 fatal), with an annual rate of embolism of 2.16%. We found a significant association between both risk scales and the incidence of embolic events (CHA: HR=1.77; 95%CI: ; p=0.001); (CHA 2 -VASc: HR=1.68; 95%CI: ; p<0.001). Conclusions: During a median follow-up of 740 ( ) days, there were 20 embolic events (4.38%), (2 fatal), with an annual rate of embolism of 2.16%. We found a significant association between both risk scales and the incidence of embolic events (CHA : HR=1.77; 95%CI: ; p=0.001); (CHA 2 -VASc: HR=1.68; 95%CI: ; p<0.001). Table 1 Baseline characteristics of patients in Group 1 ( 2 CV) and in Group 2 ( 3 CV). Patient N=326 Male 228 (69.9) Age 68 [61-74] Idiopathic AF 30 (9.3) Hypertension 261 (80.3) Diabetes 88 (27.2) Heart failure 85 (26.2) Previous thromboembolism 20 (6.2) Heart disease 128 (39.8) Coronary heart disease 62 (19.3) Dilated cardiomyopathy 21 (6.5) Valvular (mild or moderate) 25 (7.8) Congenital 6 (1.9) Hypertrophic 12 (3.7) Channelopathy 2 (0.6) Vascular disease 72 (22.1) DC cardioversion N=460 Success 400 (87) Recurrence 323 (80.7) Table 2 Annual rate of embolic events depending on CHA AND CHA 2 - VASc scores. CHA score Annual embolic rate (%) No Yes Total CHA 2 -VASc Score

6 Warfarin Dosing Algorithm Is Safe And Effective In The Elderly A. Salacata, S. Keavey Great Lakes Heart Center of Alpena, Alpena, MI, USA Introduction: The risk of stroke associated with atrial fibrillation (AF) is greatest in the elderly. However, in this age group, systemic anticoagulation (SA) is often underused due to fear of bleeding complications. This fear persists inspite of the introduction of newer anticoagulants. Ironically, in this age group, warfarin may be the safer anticoagulant despite their greater sensitivity to the drug and greater risk of complications. Dosing algorithms for W have been developed to reduce the risks of SA, the effectives in the elderly is not known. We had previously demonstrated that W dosing based on ACCP recommendations (ADR) was effective. The effect of age on the effectiveness and safety of this regimen is the subject of this study. Methods: From our anticoagulation practice we then identified 61 consecutive patients with chronic AF whose medical regimen was otherwise stable. Their INR and clinical histories were then abstracted. They were then stratified according to age into 45-60, 60-79, and greater than 80 years. The times in therapeutic (TTR), as well as time in sub therapeutic (SUB) and supra therapeutic (SUP) ranges for each group were then calculated and compared using ANOVA. Results: Majority of patients were drawn from those over 60 years of age. Using ADR the rates of effective anticoagulation was comparable among the different age groups. Likewise, safety as reflected in the time SUB or SUP was the same for all groups. Conclusions: A warfarin dosing regimen based on current ACCP guidelines results in similar rates of effective anticoagulation in all age groups, including octogenarians. The safety profile was likewise comparable across the different age groups. Table 1 Baseline characteristics of patients in Group 1 ( 2 CV) and in Group 2 ( 3 CV) >80 Mean Age 50.1+/ / /-4.8 p TTR ns SUB ns SUP ns

7 Analysis Of Problems In Oral Anticoagulants Real Clinical Practice By Patients With Atrial Fibrillation A. Strelnieks, B. Lurina, O. Litunenko, M. Vikmane, S. Sakne, G. Rancane, A. Lejnieks, A. Erglis, O. Kalejs Riga Stradins University, Riga East Clinical University Hospital, Paul Straduns Clinical University Hospital, latvian centre of Cardiology, Riga, Latvia Introduction: Old generation oral anticoagulants (OAC) have been first line medication for prevention of thrombembolic events by patients with non-valvular atrial fibrillation (AF) for a long time, although the usage of vitamin K antagonists cause a lot of problems for patients and physicians. Novel OAC promise to solve those problems, however their implementation in practice is undergoing slowly in Latvia. Aim, materials and methods: The aim of this study was to analyse main problems of OAC clinical usage by patients with non-valvular AF and by professionals treating them. The study enrolled 254 patients with nonvalvular AF under OAC therapy at two Clinical University Hospitals, Riga, Latvia. Problems associated with OAC side effects and interactions, awareness of patients, complexity of OAC usage were analyzed from patients perspective. Second study group included 245 medical practitioner with clinical experience in treatment and care of non-valvular AF patients applying OAC. Difficulties during the choice of OAC and the beginning of the therapy, patient care and communication were analyzed from the physicians point of view. Results: In patients group were 76,8% users of vitamin K antagonists (VKA) and 23,2% users of novel OAC (NOAC). In VKA group were 31,8% patients prior cardioversion in compare to 86.4% in NOAC group (p<0,001). According to CHA2DS2-VASc scale median in VKA group was score of 3 [95% CI 2-4], in NOAC group score of 2,5 [95% CI 2-4]. Statistically significant higher incidence of side effects and blleding were by VKA users 33.1% vs 3.3% (p<0.001) in NOAK group. No major bleeding were observed in NOAK group, but 17 cases in VKA group.. Less than a half of patients followed the interaction of active substances with OAC in both groups, besides patients were less informed about this aspect in compare to OAC side effects and INR controls in VKA group. By VKA users more than 50% had difficulties to adjust OAC dose and to keep the INR between 2,0 and 3,0. 31,8% had problems with INR controls while 90,6% were regulary undergoing INR control, mostly one to two times a month. In physicians group there were 13,9% cardiologists, 20,8% doctors-internists, 23,8% general practitioners, 8,9% doctors of other specialities, 32,7% resident physicians. 48,5% did use NOAC in their practice, mostly prescribing them rarely/rather rarely, but 81,3% of physicians who did not prescribe/prescribed NOAC rarely were willing to do it more often. High costs and not sufficient clinical experience were mentioned as main problems for NOAC. According to physicians the main problems for VKA are lack of understanding and cooperation from patients, poor INR control and difficulties in dose adjustment. 82% of doctors did explain interaction of active substances with OAC to their patients. Before the beginning of OAC therapy physicians mostly (>50%) considered thrombembolic events in medical history, the age of patient, vascular diseases, patients compliance and financial situation. In practice doctors most often face noncompliance, difficulties to control coagulation parameters and to keep them in therapeutic range. Conclusions: Clinical usage of OAC for AF patients is more complicated in VKA group due to side effects, complexity of use and lack of information. NOAC are more safety and with significantly less side effects in comparison with VKA.Physicians find use of NOAC less problematic and they would be ready to use NOAC in practice more often if the finansial issues were solved. Before the beginning of OAC therapy thrombembolic and bleeding risk factors are not considered enough, physicians and patients preferring social aspects of drug use.

8 Novel Oral Anticoagulants In Patients Undergoing Catheter Ablation For Atrial Fibrillation D. Bastian, K. Goehl Division of Cardiology and Electrophysiology, Medizinische Klinik 8, Klinikum Nürnberg Süd, Nuremberg, Germany Introduction: Limited data are available demonstrating the safety of novel oral anticoagulants (NOAC) in patients undergoing pulmonary vein isolation (PVI) for atrial fibrillation (AF). Methods: Overall 308 consecutive patients were pretreated four weeks either by uninterrupted vitamin K antagonists (VKA) or NOAC (dabigatran n=35, rivaroxaban n=40; only a single dose withheld the morning of the PVI). Post ablation the NOAC therapy was continued immediately after sheath removal. VKA- treated patients with INR <2.0 received enoxaparin bridging until therapeutic INR ( ) was reached. Bleeding and embolic complications were classified according to the 2012 HRS/EHRA/ECAS Expert Consensus Statement on AF ablation. Results: The total incidence of bleeding complication was significantly reduced for patients treated with NOAC (tab. 1). Especially vascular access complications occurred more often under VKA treatment plus Heparin bridging. There were no cases of tamponade and no embolic events in either group. Conclusions: CPeriinterventional anticoagulation with NOAC was safe and feasible and did not increase embolic or bleeding complications compared to uninterrupted VKA treatment. Further data from randomized controlled trials are needed to prove the safety of this approach. Table 1 Periinterventional bleeding and embolic complications