קוים מנחים לפרפור פרוזדורים - עדכון משה סויסה מרכז רפואי קפלן

INTRODUCTION The prevalence of atrial fibrillation (AF) is approximately 1.5 2% of the general population The arrhythmia is associated: with a five-fold risk of stroke a three-fold incidence of CHF higher mortality higher hospitalization rate Fortunately a number of valuable treatments have been devised in recent years that may offer some solution to this problem

INTRODUCTION In 2010, when the ESC Guidelines for AF were first issued it was already realized that an update would be necessary in 2012 Approvals of new drugs vernakalant and dabigatran In addition, reports from major clinical trials of the novel oral anticoagulants AVERROES ROCKET-AF ARISTOTLE What was not expected was the early discontinuation of the PALLAS of dronedarone nor the reports of hepatotoxicity associated with this drug

New / Modified Recommendation

Opportunistic Screening Diagnosing AF before the first complications is important recognized priority for the prevention of strokes ASSERT in patients with implanted devices Holter ECGs in epidemiological studies even short episodes of silent AF convey an increased risk for stroke

2012 focused update of the ESC Guidelines for the management of AF Stroke and bleeding risk assessment Novel oral anticoagulants Left atrial appendage closure Cardioversion with pharmacological agents Oral antiarrhythmic drug therapy Catheter ablation of atrial fibrillation European Heart Journal (2012) 33, 2719 2747

Stroke and bleeding risk assessment Risk factors for ischemic stroke/tia/ systemic embolism in patients with AF: the Swedish Cohort Atrial Fibrillation study Multivariate analysis, based on 90,490 patients without anticoagulant treatment during follow-up Friberg L et al, Eur Heart J 2012;33:1500 10

CHADS 2 = 0 CHADS 2 = 0 (Stroke rate > 1.5%) CHADS 2 = 0 CHA 2 DS 2 VASC = 0 (lone Afib), CHA 2 DS 2 VASC = 1 (>65), CHA 2 DS 2 VASC = 2 (>65, female) stroke rate of 0.84% stroke rate of 0.1.75% stroke rate of 2.69% CHA 2 DS 2 VASC = 3 (>65, femal, vasc) stroke rate of 3.2%

CHA 2 DS 2 VASc score

HAS-BLED Score

Rates of Intracranial Bleeding

AVERROES

Anticoagulation - General

Anticoagulation - NOACs

Anticoagulation - Summary The efficacy of stroke prevention with aspirin is weak, and the risk of major bleeding (and ICH) with aspirin is not significantly different to that of OAC, especially in the elderly The use of antiplatelet therapy (as aspirin/clopidogrel or less effectively aspirin monotherapy) for stroke prevention in AF should be limited to the few patients who refuse any form of OAC The CHA 2 DS 2 -VASc score is better at identifying truly low-risk patients with AF and is as good as and possibly better than CHADS 2 score

LAA Closure/Occlusion/Excision The LAA is considered the main (but not the only) site of thrombus formation in patients with AF Surgical excision or stapling of the LAA Percutaneous LAA occlusion (PROTECT AF, PREVAIL, Amplatzer Cardiac Plug Trial)

Pharmacological Cardioversion Vernakalant atrial effect AC Trail - vernakalant was: significantly more effective than placebo in converting AF of 7 days (51.7% vs 3.6%) The median time to conversion was 8 11 minutes AF post cardiac surgery (47% vs 14%) Vernakalant is superior to IV amiodarone in converting AF within 90 min (51.7% vs. 5.2%) Vernakalant is ineffective in converting AF of more than 7 days duration or typical atrial flutter

Pharmacological Cardioversion Vernakalant in IHD, HTN, HF Safety: Hypotension in patients with HF Bradycardia no excess in ventricular arrhythmia No drug-related torsades de pointes However, in HF patients NSVT occurred more often on treatment (7.3% vs. 1.6% on placebo) The QTc and QRS prolonged by 25 and 8ms

Pharmacological Cardioversion Vernakalant is contraindicated hypotension < 100 mmhg ACS within 30 days CHF NYHA class III and IV severe aortic stenosis Prolonged QT >440 ms Should be used with caution inpatients with NYHA I or II heart failure because of increased risk of hypotension Should be avoided in patients LVEF 35

Pharmacological Cardioversion

Oral Antiarrhythmic Drugs

Left Atrial Ablation

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