Atrial Fibrillation
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1 Atrial Fibrillation Quality of Life and Preventing Stroke The 14 Clinical Challenges ACC New York, Dec 9, 2017 No Disclosures
2 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
3 1,2). Acute & Chronic Management Of AF 1. D Kotecha et. al.. EHJ. 2016;37:2851 ANSD RF - <AF Death 2. EHJ 2016; 37: Simple
4 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
5 1). Gross Mechanisms of AF Aging Alcohol Genetics TJ Bunch et. al. Eur Heart J. 2016;37:2890 BW Calenda, V Fuster, V Reddy et. al. Nat Rev Cardiol 2016;13:549
6 Obesity and AF CJ Lavie et. al. J Am Coll Cardiol 2017;70:2022
7 Adipose Tissue Depots Occur Throughout The Body JJ Fuster et. al. Circ Res. 2016;118:1786
8 Definition of Epicardial Fat And Related Adipose Tissues CX Wong et. al. Eur Heart J. 2017;38:1294
9 Bariatric Surgery and the Risk of AF S Jamaly et. al. J Am Coll Cardiol 2016;68:2497
10 2) Mechanisms of AF Initiation At The Pulmonary Veins S Nattel et. al. Nat Rev Cardiol. 2016; 13: 575.
11 S Nattel et. al. Nat Rev Cardiol. 2016; 13: 575. Also Re-entry 2) Molecular Mechanisms of Focal Ectopic Firing In Paroxysmal AF
12 Natural History of AF JB Guichard et. al. J Am Coll Cardiol 2017;70:756
13 LA Tissue Fibrosis on 3D LGE CMR Scans JB King, N Marrouche et. al. J Am Coll Cardiol 2017;70:1311
14 JAMA. 2014;311(5):498 Fibrosis of the LA Wall, Blinded To The Treating Physicians: Stage 1 (<10% ), Stage 2 ( 10%-<20%), Stage 3 ( 20%-<30%), Stage 4 ( 30%).
15 Risk of MACCE Utah Stage of LAG Enhancement Severity JB King, N Marrouche et. al. J Am Coll Cardiol 2017;70:1311
16 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
17 1a). AC When?- The Prevention Of Stroke. V Fuster, JS Chinitz, Circ ; 125: 2285 Swedish AF Cohort Register (L Friberg, GYH Lip et al) Circ. 2012; 125: 2298 CHA 2 DS 2 VASc: ESC Guidelines (P Kirchhof, AJ Camm et al ) ACC / AHA / HRS 2014 A/C Prevention - Emboli >>> Bleeding, Thrombosis > Bleeding?
18 1b). To Bridge & How to Bridge for DOACs/VKAs JU Doherty, JL Januzzi et. al. J Am Coll Cardiol 2017;69:872 ORBIT=AF (BA Steinberg et al.), Circulation 2015; 131:488 Exeptions Only
19 2a) Predictors of Stroke Risk Incorporated in the CHA 2 DS 2 -VASc Schemes - Atrial Cardiomyopathy JB Guichard et. al. J Am Coll Cardiol 2017;70:756
20 LAA Structure / Function Stroke in NSR Cardiac Imaging For Assessment J Romero et. al. Nat Rev Cardiol. 2014;11:470 ENGAGE AF (DK Gupta et al.) EHJ 2014; 35:1457 LA Function / NSR? ASSERT (M Brambatti, et al.) Circ. 2014; 129:2094- LV Function / NSR? IMPACT (DT Martin et al.) EHJ; 2015; 36:1660- LV Function / NSR?
21 2b). Silent Cerebral Infarcts (SCI) Cardiac Disease And Procedures ME Hassell et. al. Nat. Rev. Cardiol. 2013;10:696 F Gaita et. al. J Am Coll Cardiol 2013;62:1990 (Italy) S Kalantarian et. al. Ann Intern Med. 2014;161: Studies, SCI
22 Silent Cerebral Ischemia in AF Correlation With Cognitive Function F Gaita et. al. J Am Coll Cardiol 2013;62:1990 (Italy) S Kalantarian et. al. Ann Intern Med. 2014;161: Studies, SCI
23 Atrial Fibrillation as a Risk Factor for Cognitive Decline and Dementia Data are drawn from the Whitehall II study, N=10,308 at study recruitment in A battery of cognitive tests was administered four time ( ) to 7428 participants -414 cases of AF-, aged years in Compared with AFfree participants, those with longer exposure to AF (5, 10, or 15 years) experienced faster cognitive decline after adjustment for sociodemographic, behavioural, and chronic diseases (P for trend=0.01). Stroke did not explain it. In adults aged years AF is associated with accelerated cognitive decline and higher risk of dementia A Singh-Manoux et al., European Heart Journal 2017; 38:2612
24 Decline In The Global Cognitive Score Function of AF A Singh-Manoux et. al. Eur Heart J. 2017;38:2612
25 Mechanisms Of AF Leading To Cognitive Decline Or Dementia HC Diener et. al. Eur Heart J. 2017;38:2619
26 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
27 1,2). Preventing Bleeding in Pts with AF-PCI Group 3 - D-adjusted vitamin K antagonist plus DAPT for 1, 6, or 12 months. Group 2 - VLD rivaroxaban (2.5 mg twice daily) plus DAPT for 1, 6, 12 Mo Group 1 - LD rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor for 12 Mo PIONEER AF-PCI (CM Gibson et. al. ) NEJM 2016;375:2423
28 1,2) CV Events in Pts with AF-PCI Group 3 - D-adjusted vitamin K antagonist plus DAPT for 1, 6, or 12 months. Group 2 - VLD rivaroxaban (2.5 mg twice daily) plus DAPT for 1, 6, 12 Mo Group 1 - LD rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor for 12 Mo PIONEER AF-PCI (CM Gibson et. al. ) NEJM 2016;375:2423
29 Long-term Treatment Of Patients On NOAC Therapy After Revascularization Elective or ACS H Heidbuchel et. al. Eur Heart J. 2017;38:2137
30 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
31 1,2). New Oral Anticoagulants - Efficacy & Safety x Dialogues in Cardiovascular Medicine 2012;17:189
32 1a). VHD Patients on Edoxaban or Warfarin in the ENGAGE AF-TIMI 48 Trial VHD was defined as history or baseline echo evidence of at least moderate aortic/mitral regurgitation, aortic stenosis, or prior valve surgery -bioprosthesis replacement, valve repair, valvuloplasty. Patients with moderate to severe mitral stenosis or mechanical heart valves were excluded from the trial. Comparisons were made of rates of stroke/systemic embolic event (SSEE) & major bleeding. VHD increased the risk of death, major adverse CV events, and major bleeding but did not affect the relative efficacy or safety of higherdose edoxaban versus warfarin in AF. R De Caterina et al., J Am Coll Cardiol 2017; 69:1372 CT January et. al. J. Am. Coll. Card. 2014; 64: e1 No Dabigatran in Mechanical HV
33 2a). Characteristics of Warfarin & NOAC Agents KE Chan et. al. J Am Coll Cardiol 2016;67:2888
34 Doses Of The Different NOACs In The 4 Large Trials In AF Patients HC Diener et. al. Eur Heart J. 2017;38:860
35 Proposed Algorithm for Oral Anticoagulant Choices in Patients With Atrial Fibrillation and Chronic Kidney Disease YC Lau et. al. J Am Coll Cardiol 2016;68: HIT...(?)
36 2b). Initiation Or Re-initiation of Oral A/C After Intracranial Haemorrhage ESC Working Group on Thrombosis (S Halvorsen et. al.) Eur Heart J. 2017;38:1455 H-C Diener et al. Eur Heart J 2017; 38: 860 Bleeding GI Tract: In 1 Week NOAC or AC
37 2c). Idarucizumab & Other Reversal Agents When available, idarucizumab is likely to be the treatment of choice for patients who present with diabigatran-induced uncontrolled or life-threatening bleeding or for those who require urgent surgery or invasive procedures. Other reversal agents are in development to reverse other NOACs. These include andexanet alfa, a recombinant truncated form of enzymatically inactive factor Xa, which binds and reverses the anticoagulant action of the factor Xa inhibitors, and PER977 (ciraparantag), a synthetic small molecule that is reported to bind to all of the NOACs. JW Eikelboon et al., Circ 2015; 132:2412 ESC Rome, 2016 Sept
38 Idarucizumab for Dabigatran Reversal Full Cohort Analysis We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100%. In emergency situations, idarucizumab rapidly, durably, and safely reversed the AC effect of dabigatran. CV Pollack et al., N Engl J Med 2017; 377:431
39 Key Measurements Before And After The Administration of Idarucizumab CV Pollack et. al. N Engl J Med 2017;377:431
40 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
41 Main Cardiac Targets of The Different Domains Of AF Management P Kirchhof. Lancet 2017;390:1873
42 J Am Coll Cardiol 2017;70:542, J Am Coll Cardiol 2016;68:1929, J Am Coll Cardiol 2017;69:1247, J Am Coll Cardiol 2017;69:1257
43 1a). Cumulative Hazard Rates Of Embolic Events According To The Pattern Of AF Occurrence T Vanassche, SJ Connolly et. al. Eur Heart J. 2015;36:281
44 1b). CHA 2 DS 2 -VASc (Recurrent AF) in Predicting Clinical Outcomes in AF After Catheter Ablation T-F Chao et al., JACC 2011; 58:2380 (Japan) 565 Pts
45 1c). AF Burden - After Catheter Ablation Several Strategies (Linq Recorder etc) EI Charitos et. al. Circulation. 2012;126:806 (Luebeck, Germ.)
46 2a) Bleeding Risk, Ischemic Stroke Risk, Indications for Left Atrial Appendage Closure KC Koskinas et. al. J AmColl Cardiol Intv 2016;9:1374
47 2b). Primary Efficacy Outcome of Watchman LAA Closure For Embolic Protection In AF PROTECT AF Over 60 Months PROTECT AF - VY Reddy et. al. JAMA. 2014;312(19): RP Whitlock et. al. Circulation. 2015;131:756
48 2c). Stroke Prevention in AF With LAA Closure PREVAIL and PROTECT AF (VY Reddy et. al.) J Am Coll Cardiol 2017;70:2964
49 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
50 Screening for Atrial Fibrillation B Freedman et. al. Circulation. 2017;135:1851
51 AF - CLINICAL CHALLENGES (14) Presentation: Simplified vs Prioritized (2) 2. Etiology: Myocardial vs Electrical (2) 3. AC Rx: When / Bridge vs TE-NSR / SCI (2) 4. AF / Stent: Triple Rx vs Double Rx (2) 5. Warf. / NOACs: Efficacy vs Safety (2) 6. Not Indicated? AC vs LAA Closure (2) 7. Screening Screening vs No Screening (2)
52 Atrial Fibrillation Quality of Life and Preventing Stroke The 14 Clinical Challenges ACC New York, Dec 9, 2017 No Disclosures
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