Modest Medtronic. Modest Boehringer Ingelheim

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1 Adults With AF (millions) Modest Medtronic Modest Boehringer Ingelheim Changing Modalities of Care for Atrial Fibrillation Jill Repoley MSN, CRNP, CCDS, CEPS, FHRS Upper and lower curves represent the upper and lower scenarios based on sensitivity analyses Go AS, et al. JAMA. 2001;285: million Americans Fewer than 1% in those under 60 years More than 11% in those over 80 years In patients with NYHA Class IV CHF prevalence of AF is 50% 25% of ICD patients found to have a-fib later at Carelink data: follow-up 68% had little or no AF 20% had Paroxysmal AF 11% Persistent AF 2% Permanent Fischer et al. Heart Rhythm 2012; 9:

2 Factor Mechanism Heart failure Induces pro-arrythmic substrate 1 Structural 2, electrical and autonomic 3 remodeling Aging Diabetes and hypertension Poorly understood Likely to involve increased anisotropy due to myocardial fibrosis 4 and connexion redistribution 5 Mechanisms not known Atrial ischemia Electrical remodeling 6 Altered Ca2+-handling promotes triggered activity Structural remodeling 6 Impaired conduction creates substrate for re-entry Mitral valvulopathy Induces 1 Atrial dilation Conduction disturbances Electrical remodeling Promote re-entry Mutations promote AF through ion channel, connexin, or structural protein disturbances PITX2 shows strongest and most consistent association with AF. 1 Transcription factor ZFHX3 and Ca 2+ - dependent K + -channel KCNN3 have also been linked to AF 1 1. Wakili R, et al. J Clin Invest 2011;121: ; 2.Li D, et al. Circulation 1999;100:87 95; 3. Ng J, et al Circ Arrhythm Electrophysiol 2011;4:388 86; 4. Hayashi H, et al. J Cardiovasc Electrophysiol 2002;13:801 8;5. Koura T, et al. Circulation 2002;105:2092 8; 6.Nishida K, et al. Circulation 2011;123: Lubitz SA, et al. Circ Arrhythm Electrophysiol 2010;3: Autonomic tone Cigarette smoking Chronic ETOH Illegal drugs Post Cardiac surgery Sleep apnea Obesity High intensity endurance exercise Long standing persistent = Greater than one year American Medical Association 2

3 Stroke More frequent arrhythmia hospitalization Reduced Quality of Life Mortality Hemodynamics: Loss of atrial kick, HF, Tachycardia induced cardiomyopathy Reynolds et al. J Cardiovasc Electrophysiol 2007; 18 (6): % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 70% of the cost of AF management is driven by inpatient care and interventional procedures EuroHeart Survey ( ) Work loss Consultations Inpatient care Interventions Drugs Diagnostics Institution consequences for increased readmissions AF is a common problem readmissions are common Alternative care models will be needed Ringborg A, et al. Europace. 2008;10:

4 SF-36 Score AF * * * * Post MI Controls 81 Slow the rate Convert Prevent recurrence 20 0 General Health Physical Function Social Function Mental Health Quality of life issues Lower scores = poorer QoL *P <.05 AF vs controls Dorian P, et al. J Am Coll Cardiol. 2000;36: Rate control Rhythm control Stroke prevention Pharmacologic AV node ablation plus pacing Pharmacologic / Pacing support may be needed at times Cardioversion PVI Surgery, Intra-operative RFA Pharmacologic Occlude / Exclude LA appendage Maintenance of Sinus Rhythm No (or minimal) Hypertension CAD heart disease Dronedarone Substantial LVH Dofetilide Flecainide Dronedarone Propafenone Sotalol Sotalol No Yes Amiodarone Catheter Catheter Amiodarone Dofetilide ablation ablation Dronedarone Amiodarone Flecainide Propafenone Sotalol Catheter ablation Amiodarone Catheter Dofetilide ablation Heart failure Amiodarone Dofetilide Catheter ablation JACC 2006; 48: Heart Rhythm 2011; 8: e1-e8. 4

5 Risk of thromboembolism unless anticoagulation initiated prior - risk greatest if a- fib present greater than 48 hours Pharmacology or electrical? 1980 s - Use incision lines to act as barriers to conduction Create compartments Maze procedure Now uses RFA or cryoablation May be performed routinely in patients undergoing CABG or mitral valve surgery An option for those who can t tolerate ACs Not Clinically Available Loop event monitors with afib algorithms Technology will help us know when we have control! Implantable loop monitors Devices with alert features to notify clinics when arrhythmias recur 5

6 Dealing with Co-morbidities HTN Sleep Apnea Thyroid conditions Obesity Creating the team: Nursing EP lab Device clinic Pharm D Outpatient/ Inpatient Integration Education sessions for patients Pharm D teamwork to monitor antiarrhythmic drugs AC clinic Shared medical appointments/ Support groups EP lab sessions/ education regarding ablation strategies Web education Tight control of co-morbidities THG establishes EP rounding service Sept 2010 Staff education Dedicated EP floor Sept 2011 Arrhythmia Unit Bed management Standardized AF order sets Sept 2011 Education sessions on Arrhythmia Unit for patients Shared medical appointments Devices to notify clinic when AF occurs Coordinated patient education materials 6

7 Cost Length of stay Small group with similar diagnosis Confidentiality Ability to combine a traditional Evaluation and Management visit with Education/ Coordination Patients experience benefit of other s questions and stories Future: Outpatient initiatives Continued patient education Ablation indications Families appreciative of interaction Aggregation Preliminary Results Press Ganey and HCAHPS scores improved FY 10 FY 11 FY DRG 308 cost DRG 309 cost DRG 310 cost Length of stay 7

8 CHA2DS2VASc Newer Anticoagulants Dronedarone New ablation modalities C CHF (1) H Hypertension (1) A Age (1) D Diabetes (1) S2 TIA or Stroke (2) 0 = ASA 1 = Either 2 = Warfarin, Dabigatran, Rivaroxaban, Apixaban C = CHF (1) H = HTN (1) A2 = Age > 75 (2) D = Diabetes Mellitus (1) S2 = Stroke/ TIA (2) V = Vascular Disease (1) A = Age (1) S = Sex (1) Lip et al. Chest 2010; 137:

9 Newer risk stratification schema Low risk (0 points)= annual stroke events <0.5% Intermediate risk (1 point)= 1.1% High risk ( 2 or more points) = 4.9% Released November 2010 Direct thrombin inhibitor RE-LY trial Indication: to reduce the risk of stroke and systemic embolism in pts with non-valvular AF iphone app: Qx calculate Lip et al. CHEST 2010; 137 (2): Connolly et al. N Engl J Med 2009; 361: Factor Xa inhibitor ROCKET AF trial ARISTOTLE Factor Xa inhibitor Patel et al. NEJM 2011; 365: Granger et al, NEJM 2011; 365:

10 ASA plus Plavix better than ASA alone, albeit with higher bleeding risk ACTIVE A N Engl J Med. 2009; 360: Score to assess one year risk of major bleeding Hypertension 1 point Abnormal renal or liver function 1 point each Stroke 1 point Bleeding 1 point Labile INRs 1 point Elderly (age > 65) 1 point Drugs or alcohol - 1 point each Pisters. Chest /03/18/chest Control approach (better than meds) - CABANA RFA Goal Isolation of pulmonary vein triggers Newer procedure to use cryoablation 10

11 The fluoroscopy images show the ablation catheter (ABL) in the left anterior oblique (LAO) and right anterior oblique (RAO) projections. LSPV LIPV RSPV RIPV Usually 12 weeks of antiarrhythmic drug post procedure At least 6 months of coumadin post procedure Close follow up during the first 6 months Second procedures not uncommon Monitors needed post procedure for asymptomatic patients 11

12 A Safe Approach to PVI STOP-AF presented ACC 2010: ArticFront Cardiac Cryoablation Catheter System superior over anti-arrhythmic drugs FAST PVI - presented Cardiostim 2010: shorter procedure times with anatomically designed catheter Removes heat from the tissue Leads with a wave of hypothermia Ablates at the point of balloon contact Hypothermic Zone Ablation Zone (sub-zero) ILR to assess rhythm control Pacer/ Defibrillator data to assess atrial fibrillation burden Using remote data/ Alerts to monitor asymptomatic events % of patients hospitalized for HF 25 HF Event Rate (% of monthly follow-ups) Good Rate Control (No days with AF V-rate >90 bpm) Poor Rate Control (>1 day with AF V-rate >90 bpm) Adjusted HR: 2.14; 95% CI: ; p<0.001 Patients with AF 6 4 Patients without AF Reference 2 No 4 Days 1-6 Days > 7 Days All 30 Days No AF AF>6 hrs AF>6 hrs AF>6 hrs AF>23 hrs Months AF Burden Sarkar et al. Presented ACC 2011 Time to First HF Hospitalization 12

13 Survival p < % Q4: >98% (n=2707) Q3: 95-98% (n=2708) Q2: 89-95% (n=2707) Q1: <89% (n=2708) 70% 69% 64% Time since Implant (years) Ousdigian; presented HRS 2010 Fischer et al. Heart Rhythm 2012; 9: Ablation techniques will be refined Medications that target the atrium Genetic research Cell transplant Devices with more automaticity and remote capablities Predictive tools Upstream therapies 13

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