Etienne Aliot. University of Nancy - France

Transcription

1 Etienne Aliot University of Nancy - France

2 Disclosures Consulting fees : - Bayer, Boehringer Ingelheim,GSK, MedaPharma, Pfizer/BMS,Sanofi Aventis. - Biotronik,Medtronic,St Jude Medical.

3 Electrical vs Pharmacological AF Conversion Indications Electrical Cardioversion Pharmacologic Cardioversion AF 48 h duration (+) +++ AF 7 d + + AF > 7 d +++ (+) AF pretreated with ADD +++ (+) Amiodarone pretreatment +++

4 Anesthetist assessment before cardioversion Digoxin, K+, INR, ACT before cardioversion Fasting and steady state, perfused, reanimation room Short duration anesthesia (Propofol, 1cc/10Kg) Adhesive + gelled electrodes +++ Rhythm, arterial pressure, O² saturation permanent monitoring before, during and at least 3 hour after cardioversion

5 DCC Low impedance shock is needed Electrodes diameter (inverse relationship between surface and impedance/current density) : 8 to 12 cm Electrode/Skin interface : gelled electrodes Obesity, trans-thoracic diameter (DCC during expiration or thoracic compression) Defibrillator : synchronized on the R wave +++ Biphasic shocks are more efficient +++

6 Stroke risk if poor anticoagulation (1 to 2%) VF if wrong R wave synchonization, hypok+, digitalic overload, or myocardial ischaemia... Beware of refractory VF if digitalic overload +++ Bradycardia if SSS or AV block (be careful if slow AF or AAD associations) Myocardial injury : high energy iterative shocks (>400 Joules) and small diameter electrodes (Warnes, 1975) Pacemaker or ICD dysfunction ESC Guidelines,2006,2010

7 520 pts No VA arrhythmia No Stroke or TIA Brady Events : 2% 2 sinus bradycardia 2 junctional rhythm 5 second-degree AVblock 3 PM Morani G,et al Europace 2010

8 Cardioversion in patients with PM and ICDs The electrode paddle at least 8 cm from the battery, and the antero-posterior positioning is recommended Biphasic shocks are preferred because they require less energy for AF termination In PM-dependent patients, an increase in pacing and sansing thresholds should be anticipated but is clinically irrelevant (Manegold JC,EHJ,2007) After cardioversion, the device should be interrogated and evaluated to ensure normal function ESC Guidelines, Europace 2010

9 Electrical Cardioversion «Optimization» ESC Guidelines, 2006,2010

10 N = 161 Amiodarone 400 mg BID x 2 weeks Spontaneous reduction : 26/123 (21 %) No difference in DCC success rate Adverse events Placebo Chest infection Short-term Amiodarone Rash Suspected pulmonary fibrosis (not proven) Bradyarrhythmia (PPM) Bradyarrhythmia Intolerance Channer K, AHJ 2004

11 Risks of electrical cardioversion in patients with structural heart disease In case of underlying structural heart disease, the following risks can be theoritecally increased : - Risks of anesthesia - Arrhythmic risk (VF, bradyarrhythmias) - Thromboembolic risk - Possible risk of myocardial stunning (?) In fact the risk seems to be mainly increased in patients with severe heart failure

12 Pharmacologic Conversion of AF Drug Dose Efficacy Acute Side Effects Flecainide mg po 55-85% Hypotension, rapid AFL Propafenone mg po 25-85% Hypotension, rapid AFL Amiodarone 150 mg bolus, 1 mg/min 35-95% Hypotension, bradycardia Ibutilide 1 mg IV, then repeat 50-75% QT prolongation, TdP Dofetilide 0.5 mg po BID 30% QT prolongation, TdP Vernakalant 3 mg/kg, then 2 mg/kg IV 35-55% Hypotension Tedisamil mg/kg IV 45-55% QT prolongation, TdP

13 ECG at day 4 (Amiodarone, 600 mg IV/day)

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15 Drug induced Atrial Flutter AFl + class Ic

16 Outpatient treatment of recent-onset AF «Pill-in-the-Pocket» approach Adverse effect : 12/165 (7 %) ns 54.5 Total number of episodes for the group per month P < : AF flutter with rapid AV conduction P < : non cardiac side effects (nausea, asthenia, vertigo) Paroxysms of AF Emergency visits Hospitalizations Previous year Pill in the Pocket treatment period Alboni P, NEJM 2004

17 Ibutilide Polymorphic Ventricular Tachycardias 40 Number of patients Any PVT Sustained PVT 2 previous episodes of PVTns Time from start of infusion NB : TDP + QT prolongation : 4 %, (Oral NEJM 1999, Patsilinakos Am J Cardiol 2010)

18 Vernakalant - AVRO IV Vernakalant IV Placebo Amiodarone Screen R 240 patients 90 minutes 6 hrs 7 Days AF 3-48 hr No NYHA IV or unstable IV Placebo Vernakalant IV Amiodarone 1 0 Endpoint: Conversion to sinus rhythm at 90 minutes 2 0 Endpoint: Symptom relief at 90 minutes

19 Primary Efficacy Endpoint* Results Conversion from AF to SR within 90 Minutes * The primary efficacy endpoint was the proportion of subjects with conversion of AF to SR within 90+3 minutes of first exposure to study medication for a minimum duration of 1 minute

20 Summary of SAEs SAEs (0-24 hours) Vernakalant (N=116) Amiodarone (N=116) Sinus Bradycardia 0 1 (0.9%) Cardiac Arrest 1, (0.9%) Ventricular Tachycardia 1, 2 1 (0.9%) 0 Atrial Thrombosis 1 (0.9%) 0 Angina Pectoris 1, 2 1 (0.9%) 0 Hypersensitivity 1, 2 1 (0.9%) 0 Syncope 1 (0.9%) 0 1 Considered related by investigator 2 Resulted in discontinuation

21 Common AEs in the First 24 Hours Post-dose 0-2 Hours 2-24 Hours Vern (N=116) Amio (N=116) Vern (N=116) Amio (N=116) Any AE 32 (27.6%) 10 (8.6%) 21 (18.1%) 15 (12.9%) AF (3.4%) 0 Nausea 3 (2.6%) (1.7%) Dizziness 1 (0.9%) 0 2 (1.7%) 3 (2.6%) Dysgeusia 8 (6.9%) Cough 4 (3.4%) (1.7%) Sneezing 4 (3.4%) Hypertension 3 (2.6%) N.B. Common AEs defined as >2 patients in either group

22 Drugs for pharmacological conversion of AF Drug Dose Follow-up dose Risks Guidelines,ESC 2010

23 Conclusion AAD DCC FA<7days Easy to perform No GA needed Pro-arrhythmia risk Efficiency Stroke risk

24 Current Options for Acute Cardioversion of AF DC Cardioversion IV Agents Pill-in-Pocket Oral Flecainide Oral Propafenone Acute clinical deterioration Previously required cardioversion Patient taking antiarrhythmics QTc 460 msec Length of AF 1 month QTc 460 msec Short duration AF No underlying HD No clinical CHF Anaesthesia risk (e.g., COPD) After recent meal Patient preference Indication for use not approved in US For oral agents High single dose Minimal structural heart disease