Atrial Fibrillation: Guidelines through clinical cases and 2010 updates

Transcription

1 Atrial Fibrillation: Guidelines through clinical cases and 2010 updates Samy Claude ELAYI Cardiac Clinical Pacing and Electrophysiology

2 World incidence 720, 000 new cases / year World prevalence 5.5 million AF prevalence increasing with aging of population AF: PUBLIC HEALTH PERSPECTIVE Feinberg WM: Arch Intern Med 1995/ Murgatroyd F and Camm AJ: Lancet 1993

3 When talking about atrial fibrillation treatment, two separate issues: 1/ Prevent thrombo-embolic stroke Coumadin/ASA/plavix/none/Dabigatran 2/ Manage the AF rhythm Rate control/rhythm contol

4 Clinical case 1 65 yo male PMH: HTN Meds: metoprolol 50 mg BID Comes for regular f/u visit, no symptoms with a normal daily activity. Clinically: irregular heart beat.

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6 You discussed with the patient the potential risk of stroke. What medication would you consider daily regarding this risk? No medication Start Aspirin 81 mg Start Aspirin 325 mg Start Plavix Start Coumadin

7 STROKE RISK/ ANTITHROMBOTIC THERAPY AND AF Moderate-Risk Factors High-Risk Factors Heart failure Hypertension Previous stroke, TIA or embolism Mitral stenosis Age greater than or equal to 75 y LV ejection fraction 35% or less Diabetes mellitus Risk Category Recommended Therapy_ No risk factors One moderate-risk factor Aspirin 81 to 325mg/day or none* Aspirin 81 to 325 mg daily, or warfarin (INR 2.0 to 3.0, target 2.5) Any high risk factor or >1 moderate risk factor warfarin (INR 2.0 to 3.0, target 2.5) * Age less than 60 y, no heart disease (lone AF) 2006 guidelines for the management of patients with AF

8 Stroke risk and CHADS2 score For non valvular AF n Congestive Heart Failure +1 n Hypertension +1 n Age > 75 yo +1 n Diabetes +1 n Prior Stroke/TIA +2 Then classification as: Low-risk = 0 High-risk >2

9 STROKE RISK/ ANTITHROMBOTIC THERAPY AND AF Moderate-Risk Factors High-Risk Factors Heart failure C Previous stroke, TIA or embolism S2 Hypertension H Mitral stenosis Age greater than or equal to 75 y A LV ejection fraction 35% or less Diabetes mellitus D Risk Category Recommended Therapy_ No risk factors One moderate-risk factor Aspirin 81 to 325mg/day or none* Aspirin 81 to 325 mg daily, or warfarin (INR 2.0 to 3.0, target 2.5) Any high risk factor or >1 moderate risk factor warfarin (INR 2.0 to 3.0, target 2.5) * Age less than 60 y, no heart disease (lone AF) 2006 guidelines for the management of patients with AF

10 You discussed with the patient the potential risk of stroke. What would you do next regarding this risk? Not start anything Start Aspirin 81 mg Start Aspirin 325 mg Start Plavix Start Coumadin

11 You decided to start Aspirin 325 mg and determine during the f/u that your patient is always in AF (=persistent AF).

12 AF CLASSIFICATION PAROXYSMAL AF PERSISTENT AF PERMANENT AF Terminates spontaneously AF can be converted to SR (shock or drug) Yes No No N/A Yes No Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE. 1992;20:

13 What would you do next for this patient with HTN and asymptomatic persistent AF? Restore sinus rhythm with cardioversion (RHYTHM CONTROL) Keep the patient in AF but adjust the metoprolol dose to prevent fast ventricular heart rate to avoid potential tachycardia induced cardiomyopathy with heart failure (RATE CONTROL) Send the patient for an ablation

14 2006 guidelines for the management of patients with AF

15 Rate control Rhythm control 2006 guidelines for the management of patients with AF

16 What would you do next for this patient with HTN and asymptomatic persistent AF? Restore sinus rhythm with cardioversion (RHYTHM CONTROL) Keep the patient in atrial fibrillation but adjust the metoprolol dose to prevent fast ventricular heart rate to avoid potential tachycardia induced cardiomyopathy and heart failure (RATE CONTROL) Send the patient for an ablation

17 Rate vs. Rhythm control The AFFIRM Trial Design in the mid 1990 to help manage AF Potential benefit of maintaining SR: better survival lower risk of stroke better quality of life Hypothesis: maintenance of SR with AAdrugs would improve mortality compared to rate control of AF with AV nodal blockers AFFIRM NEJM 2002;347:

18 Rate vs. Rhythm control The AFFIRM Trial Inclusion criteria One or more recent episodes of AF of > 6 hours (excluded permanent AF). Patients with at least one clinical risk factor for stroke: age> 65 HTN DM CHF LVEF < 40% prior stroke AFFIRM NEJM 2002;347:

19 AFFIRM limitation Patients with frequent or severe symptoms were largely excluded Although this subgroup would benefit the most from SR Constitutes >1/3 of all AF patients

20 Rate vs. Rhythm control The AFFIRM Trial 4060 patients were randomized to: 1. Rhythm control (maintain SR as much as possible using cardioversions and AAdrugs). 2. Rate control (with AV nodal blockers). AFFIRM NEJM 2002;347:

21 It does not mean SR=AF in term of mortality. Primary endpoint: overall mortality Management of AF with the rhythm-control strategy offers no survival advantage over the rate-control strategy > Current guidelines

22 Sinus Rhythm vs. AF AFFIRM study did not compare SR vs AF, but: an ineffective and toxic tool to maintain SR (AAdrugs) versus maintaining AF with rate control drugs. AFFIRM study can not be extrapolated to Sinus rhythm and AF are equivalent in term of mortality. SR is better than AF mortality wise.

23 Clinical impact of AF on mortality AF has a 1.5- to 1.9-fold increased risk of mortality in the general population * compared to sinus rhythm 4.2-fold increased risk for CV mortality in lone AF; 2.5-fold increased risk for mortality in HF; 4.5-fold increased risk for mortality in acute coronary syndromes. Benjamin et al Circulation 1998;98:946-52

24 AFFIRM conclusion: Trying to maintain sinus rhythm with an aggressive strategy using currently available drugs (relatively ineffective to maintain SR or with major side effects) is not better in term of mortality than keeping AF rate controlled in patients with moderately, minimally or not symptomatic AF. The impact of maintaining SR on mortality with ablation or potential new drugs (less toxic, more effective to maintain SR) is unknown.

25 65 yo male HTN metoprolol asymptomatic persistent AF You decided to cardiovert the patient and this restored normal sinus rhythm. However, 4 months latter, he is back in AF and still asymptomatic. What would you do next? Start cardioversion again rate control the AF

26 2006 guidelines for the management of patients with AF

27 65 yo male HTN metoprolol asymptomatic recurrent persistent AF You decided to cardiovert the patient and this restored normal sinus rhythm. However, 4 months latter, he is back in AF and still asymptomatic. What would you do next? Start cardioversion again Rate control the AF

28 61 year old male Clinical case 2 PMH: HTN treated with amlodipine (Norvasc) Complaining of episodes of palpitations for the last year: several episodes/month, from few minutes to 1 hour spontaneous termination. Feels dizzy, SOB and exhausted. He went to the local ED 6 weeks ago and was told he has "A-fib." Had heart echo (EF 65%)/TSH normal. Was started on ASA and metoprolol 150 mg BID and asked to f/u with his PCP. Clinical exam: unremarkable with regular heart beat

29 The patient still has frequent palpitations despite 150 mg BID of metoprolol. His heart rate is around 50 bpm. What would you do next? Consider increasing metoprolol Consider starting antiarrhythmic drugs Consider sending the patient for an AF ablation Consider sending the patient for a pacemaker and AV node junction ablation

30 2006 guidelines for the management of patients with AF

31 The patient still have frequent arrhythmia symptoms despite 300 mg of metoprolol. What would you do next? Consider increasing metoprolol Consider starting antiarrhythmic drugs Consider sending the patient for an AF ablation Consider sending the patient for a pacemaker and AV node junction ablation

32 Drugs used in 2010 for AF FOR RHYTHM CONTROL (maintain SR) Class IC Flecainide (Tambocor*) Propafenone (Rythmol*) Class III Amiodarone (Cordarone*;Pacerone*) Sotalol (Betapace*) Dofetilide (Tikosyn*) Dronedarone (Multaq*) FOR RATE CONTROL (control AF) Betablockers/ calcium blockers (diltiazem/verapamil)/ digoxin

33 61 yo male HTN normal heart echo no CAD nor heart failure very symptomatic AF failed rate control. Which antiarrhythmic could be started?

34 61 yo male HTN normal heart echo no CAD nor heart failure very symptomatic AF failed rate control. Which antiarrhythmic could be started? Depends on the heart condition

35 2006 guidelines for the management of patients with AF

36 The patient was started on flecainide (IC) 50 mg BID, well tolerated. At his 2 months f/u, he reports a few episodes of AF<5 min still symptomatic. What would you consider? Continue same medications and f/u Increase the dose of flecainide to the standard dose of 100 mg BID Change antiarrhythmic drug Consider sending the patient for an AF ablation

37 The patient was started on flecainide 50 mg BID, well tolerated. At his 2 months f/u, he reports a few episodes of AF<5 min still symptomatic. What would you consider? Continue same medications and f/u Increase the dose of flecainide to the standard dose of 100 mg BID Change antiarrhythmic drug Consider sending the patient for an AF ablation

38 You increased the flecainide to 100 mg BID. The patient did well and did not came back to see you for seven months. One day, he calls and wants to been seen quickly because he is short of breath and has bilateral pedal edema for the last few days. Clinically, he is tachycardic around 160 bpm irregular and is in congestive heart failure with bilateral crackles and a systolic BP of 90 mmhg.

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40 You send him to the ER where he was admitted. His left ventricular EF is now 30% on echo. What do you expect them to do? Keep the patient on aspirin Initiate coumadin Cardiovert the patient to sinus rhythm after TEE Initiate long term amiodarone Initiate immediately dronedarone (Multaq*)

41 STROKE RISK/ ANTITHROMBOTIC THERAPY AND AF Moderate-Risk Factors High-Risk Factors Age greater than or equal to 75 y Hypertension Previous stroke, TIA or embolism Mitral stenosis Heart failure LV ejection fraction 35% or less Diabetes mellitus Risk Category Recommended Therapy_ No risk factors One moderate-risk factor Aspirin 81 to 325mg/day or none* Aspirin 81 to 325 mg daily, or warfarin (INR 2.0 to 3.0, target 2.5) Any high risk factor or >1 moderate risk factor warfarin (INR 2.0 to 3.0, target 2.5) * Age less than 60 y, no heart disease (lone AF) 2006 guidelines for the management of patients with AF

42 You send him to the ER where he was admitted. His left ventricular EF is 30% on echo. What do you expect them to do? Keep the patient on aspirin Initiate coumadin Cardiovert the patient to sinus rhythm after TEE Initiate long term amiodarone Initiate immediately dronedarone (Multaq*)

43 Amiodarone the most effective but side effects +++: -life threatening pulmonary fibrosis -thyroid (hyper or hypo) -QT prolongation (ventricular arrhythmias) -ocular, neurologic, dermatologic, liver

44 You send him to the ER where he was admitted. His left ventricular EF is 30% on echo. What do you expect them to do? Keep the patient on aspirin Initiate coumadin Cardiovert the patient to sinus rhythm after TEE Initiate long term amiodarone Initiate immediately dronedarone (Multaq*)

45 Dronedarone (Multaq*) Class III K blockers Available in the US since august 2009 Wei Sun et al Circ 1999;100:

46 Dronedarone (Multaq*) Advantages -no lung or thyroid toxicity (with a half life <24h) -reduces hospitalization for AF (ATHENA trial NEJM 2009) -no hospital admission for initiation/ no special certification Limits -Contra-indication in unstable heart failure (IV) or class II III< 1 month -efficacy less than amiodarone (-12%) -cost

47 Dronedarone Dronedarone Dronedarone Dronedarone? 2006 guidelines for the management of patients with AF

48 You send him to the ER where he was admitted. His left ventricular EF is 30% on echo. What do you expect them to do? Keep the patient on aspirin Initiate coumadin Cardiovert the patient to sinus rhythm after TEE Initiate long term amiodarone Initiate immediately dronedarone (Multaq*)

49 The patient has been cardioverted. Patient has been discharged on coumadin and Tikosyn 500 mcg BID (maximal dose). He comes at his 2 months f/u after repeating a new heart echo: EF 70% (arrhythmia induced cardiomyopathy). He still reports palpitations and dizziness which are impairing his quality of life.

50 So 61 yo male HTN very symptomatic AF failed two AADS at maximal doses. What would you do next? Stop the tikosyn and start sotalol Send the patient for AF ablation

51 So 61 yo male HTN very symptomatic AF failed two AADS at maximal doses. What would you do next? Stop the tikosyn and start sotalol Send the patient for AF ablation

52 I II III avr avl avf V1 V2 V3 V4 V5 V6

53 Posterior Basal View R. pulmonary artery Left Atrium L. pulmonary artery L. auricle L. superior pulmonary vein L. atrium L. inferior pulmonary vein R. superior pulmonary vein R. inferior pulmonary vein Coronary sinus Netter F. Atlas of Human Anatomy. 1989;Plate 202.

54 Myocardial sleeve Veno-atrial junction LA Left atrium LSPV Lung hilum

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56 Atrial Fibrillation: Catheter ablation of PV focus The fluoroscopy images show the ablation catheter (ABL) in the left anterior oblique (LAO) and right anterior oblique (RAO) projections.

57 Complex procedure Esophagus temperature monitoring probe LA CT to define the anatomy more precisely Ablation catheter Circular mapping catheter Straight mapping catheter Mapping system during ablation Intracardiac echo probe

58 Paroxysmal AF Targets mainly the trigger by disconnecting the pulmonary veins from the rest of the left atrium

59 Ablation in paroxysmal AF Elayi et al. Heart rhythm 2006

60 Persistent AF May need to target -the trigger (isolation of the pulmonary veins) -the rest of the left atrium and sometimes right atrium (to modify the atrial substrate capable of sustaining persistent AF)

61 Ablation in persistent AF Elayi et al. Heart rhythm 2008

62 Main complications of AF ablation Stroke (0.5 to 1%)+++ like left heart cath Pericardial effusion/tamponnade Others: hematomas; PV stenosis; fistula with esophagus, phrenic nerve paralysis

63 Ablation versus Drugs Advantages -Relative efficacy with a success rate around 70-90% in paroxysmal AF and 50-75% in persistent AF (less successful in enlarged atrium). -Potential cure (no life long treatment) -Potentially stop coumadin Disadvantages -Immediate procedure risk -Operator dependant (long learning curve) -Lack on very long term data

64 2006 guidelines for the management of patients with AF

65 Maintenance of sinus rhythm Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients with little or no LA enlargement (Class IIA; level of evidence C) 2006 guidelines for the management of patients with AF

66 AF Ablation summary GOAL=Alleviate AF symptoms Relatively effective procedure especially in paroxysmal patients For symptomatic AF After failure of at least one antiarrhythmic drug With potential significant complications long term survival and data unknown (>10 years)

67 Dabigatran Oral direct thrombin inhibitor Advantages over coumadin/enoxaparin: -oral -no routine anticoagutation checks (INR) -few drugs interaction Disavantages: -BID with short half life (compliance) -Liver toxicity RE-LY trial NEJM 2009

68 Dabigatran Was compared to coumadin at two doses (RE-LY trial): -110 mg BID: same embolic stroke rate but less hemorrhagic stroke than coumadin mg BID: less embolic stroke but same hemorrhagic stroke than coumadin FDA approval last week RE-LY trial NEJM 2009

69 Conclusion In AF, first evaluate thrombo-embolic risk and decide aspirin versus coumadin Several Rx options are available for the rhythm Asymptomatic patients: -Make sure patient really asymptomatic -Rate control is an acceptable option (try cardioversion once reasonable) Symptomatic patients: -AADrugs are always the first option -Failure of AADrugs : ablation

70 Thank you very much If further questions: Phone:(859)

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72 * RA LA RV LV

73 1 PAC *

74 AF wavelets 400 to 600 bpm AV node filters 1 the atrial 1 1 activity and 1 determines the ventricular rate

75 RHYTHM CONTROL (antiarrhythmic drugs, Ablation) * 1 1 1

76 RATE CONTROL (AV nodal blockers filter AF waves) * 1 1 1

77 What would you do next for this patient with HTN and asymptomatic persistent AF? Restore sinus rhythm with cardioversion (RHYTHM CONTROL) Keep the patient in atrial fibrillation but adjust the metoprolol dose to prevent fast ventricular heart rate to avoid potential tachycardia induced cardiomyopathy and heart failure (RATE CONTROL) Send the patient for an ablation

78 Clinical case 3 87 yo female PMH: HTN DM several surgeries COPD AF: permanent with several hospitalizations over the last 2 years for CHF and ventricular heart rate in the despite digoxin and metoprolol which alternates with episodes of heart rate in the 30 s very tired and dizzy Clinically systolic BP in the 90 s

79 What would you do next? Add another AV nodal blockers (diltiazem) Send the patient for a pacemaker Send the patient for a pacemaker and AV node ablation

80 AVN ABLATION AND PACEMAKER Rationale: AVN ablation prevent the fast atria rate (500 bpm) to conduct rapidly and irregularly to the ventricle by disconnecting atria and ventricles The ventricle can be paced regularly.

81 AV Node Ablation

82 AV Node Ablation

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84 AVN ablation and pacing Only for selected patients with: symptomatic AF failed AADs (rhythm or rate control) not good candidate for ablation

85 Clinical case 4 64 yo male h/o GERD Comes to see you in regular f/u visit. used to be very active but now cannot do any significant effort because of fatigue so limit his activity and doing OK Clinically irregular heart beat 85 bpm

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87 You do a general workup (CBC ) than is negative. What would you do next? f/u in a few months Do a 24 hours holter to make sure he is correctly rate controlled Try to cardiovert him

88 Hemodynamics Symptoms Assess symptoms is critical because it is going to guide your treatment

89 Hemodynamics Symptoms Reduced cardiac output -Hypotension -Pulmonary and/or systemic CHF Fast/slow/irregular ventricular rate is symptomatic for many patients, resulting in: Palpitations Dyspnea Dizziness Post conversion pauses/ syncope

90 Hemodynamics Symptoms Inappropriate increases in heart rate with exercise may cause -exercise intolerance +++ -fatigue +++ If chronic cardiomyopathy with low EF Increase myocardial oxygen demand may precipitate coronary ischemia.

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92 (ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation)

93 CONCLUSION Several AF treatment options available AADs always 1 st option to rhythm control before ablation Rate control is an acceptable primary therapy: -if reach target (80 bpm at rest and 110 bpm exercise) -consider DCV for the 1 st documented AF, even if not symptomatic -no data to compare mortality with ablation and rate control Patient stays symptomatic despite rate/rhythm control consider ablation AVN ablation+ pacemaker last resort

94 Symptoms and AF (2) Atrial fibrillation conducting quickly to the ventricles can lead to tachycardia induced dilated cardiomyopathy with low ventricle ejection fraction. If rate control strategy is chosen, rate control should be efficient.

95 Dronedarone jeff Multaq is contraindicated in patients with NYHA Class IV heart failure, or NYHA Class II-III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic. The Athena trial characterized recent decompensation as occurring in the previous 4 weeks. No criteria were used for ejection fraction however Athena had 1165 patients with Class 1 or 2 CHF and 200 patients with Class 3. There were 179 patients with a LVEF <35% and 4365 patients with LVEF >35%. If a patient has CHF Class 1, 2, or 3, has a normal EF, and is Clinically stable. Multaq may be used just as it was in Athena. If they are becoming unstable they should not be started or the medication should be stopped.

96 dronedarone Pros: -no hospital admission/ drug certification -no renal excretion -should replace IC drugs -multi channel, also AV nodal blocade (per rep, dim HR in AF by bpm) Cons: -longer study f/u 1.5 year -efficacy -12% compared to amiodarone (dionysos) QT -indicated in parox AF -CI in class IV and class 2 to 3 recent within one month= unstable CHF

97 His main concern is the risk of stroke (father had a massive stroke). What would you do regarding his treatment: Keep on ASA Stop ASA and start clopidogrel (Plavix) Stop ASA and start coumadin

98 ACC/AHA/ESC guidelines 2006

99 Rx options for recurrent AF Rhythm control [keep the patient in SR] with antiarrhythmics drugs (AADs) with ablation - Catheter ablation - Surgery (Maze) With hybrid approach: combining AADs and/or ablation and/or pacemakers Rate control [keep patient in AF but control ventricular rate] with AV nodal blockers with AV nodal ablation and pacemaker