Updates in Atrial Fibrillation Michael Curley, MD Cardiac Electrophysiologist Wheaton Franciscan Medical Group #1 Most common heart rhythm disturbance 1 in 4 Americans over 40 will be diagnosed 3,500,000 Number of Americans known to have A fib Circulation 2004;110:1042 1046 Circulation 2010;121: e1 e170. 1
750,000 Number of hospitalizations annually $6,000,000,000 Annual expenditure in US on A fib care www.cdc.gov/dhdsp/data_stastistics/fact_sheet/fs_atrial_fibrillation.htm www.cdc.gov/dhdsp/data_stastistics/fact_sheet/fs_atrial_fibrillation.htm Am J Cardiol 2009;104:1534 1539 Impact of A Fib Impact of A Fib Markedly reduces quality of life Increases risk of stroke Increases risk of developing heart failure Increases likelihood of hospitalization Increases risk of mortality N=6514 J Am Coll Cardiol 2000;36:1303 1309 Arch Intern Med 1987;147:1561 1564 Am J Cardiol 1998;82:2N 9N Circ Cardiovasc Qual Outcomes 2011;4:313 4320 JAMA Neurol. 2015;72(11):1288-1294 2
Impact of A Fib Individuals with AF are 2 times more likely to develop dementia than those without AF JAMA Neurol. 2015;72(11):1288-1294 JAMA 2007;298(23):2768-2778 N Engl J Med 2015;372:1812 1822 N Engl J Med 2015;372:1812 1822 N Engl J Med 2015;372:1812 1822 3
Paroxysmal, N=234 Persistent, N=589 Eur Heart J 2015;36:1812 1821 N Engl J Med 2015;372:1812 1822 Persistent (long standing), N=202 J Am Coll Cardiol 2012;60:1921 9 A Fib Risk Factors A Fib Risk Factors A Fib A Fib 4
A Fib Risk Factors Risk Factor Modification: OSA J Am Coll Cardiol 2007;49:565 71 J Am Coll Cardiol EP 2015;1 2:41 51 Risk Factor Modification: Obesity Risk Factor Modification: Comprehensive N=281 J Am Coll Cardiol EP 2015;1 2:41 51 J Am Coll Cardiol 2014;64:2222 31 Risk Factor Modification: Comprehensive Risk Factor Modification: Comprehensive J Am Coll Cardiol 2014;64:2222 31 J Am Coll Cardiol 2014;64:2222 31 5
J Am Coll Cardiol 2014;64:e1 e76 CHADS 2 VASc Score CHADS 2 VASc Score Stroke risk/year Congestive Heart Failure 1 0 1 1.3 % Hypertension 1 Age 65 74 1 Diabetes 1 Stroke or TIA 2 Vascular disease 1 2 2.2 % 3 3.2 % 4 4.0 % 5 6.7 % 6 9.8 % Coumadin (warfarin) Direct Oral Anticoagulants Pradaxa (dabigatran) Xarelto (rivaroxaban) Eliquis (apixaban) Age 75 2 Female 1 7 9.6 % 8 6.7 % Savaysa (edoxaban) Maximum score 9 9 15.2 % For those with a score of 2, anticoagulation is recommended J Am Coll Cardiol 2014;64:e1 e76 Warfarin Direct Oral Anticoagulants PROs Tried and tested Approved for use with mechanical valves Inexpensive CONs Bleeding risk Many interactions with foods and other drugs Regular INR monitoring Delayed onset and offset PROs No regular monitoring Few interactions with foods and other drugs Rapid onset and offset Decreased intracranial bleeding CONs Bleeding risk Must be avoided in patients with mechanical valves and advanced kidney disease Very expensive J Am Coll Cardiol 2014;64:e1 e76 J Am Coll Cardiol 2014;64:e1 e76 6
Milwaukee Journal Sentinel August 2015 Anticoagulant Reversal Expensive alternative. Key concerns sited in article 58,000 people have had a serious side effects from [the new drugs]. That compares with more than 8,000 for warfarin. None of the newer drugs has an approved antidote. Milwaukee Journal Sentinel August 2015 N Engl J Med 2015;373:511 520 Anticoagulant Reversal Anticoagulant Reversal N Engl J Med 2015;373:2413 2424 Europace 2015; doi:10.1093/europace/euv030 7
Anticoagulant Reversal Europace 2015; doi:10.1093/europace/euv030 > 90% of thrombus accumulation originates in the LAA Ann Thorac Surg 1996;61:755 759 Circulation 2006; 114:e513 N Engl J Med 2009;360:2601 2602 J Am Coll Cardiol 2015;65:2614 2623 Lancet 2009; 374: 534 542 8
Considerations Watchman has not been studied against DOACs Key trials included warfarin eligible patients Relatively high early complication rate Limited long term data: signal for late increase in CVAs Not all thrombi in patients with AF originate in LAA Will real life outcomes reflect trial data? Take Home Points The clinical and economic burden of AF is large and will continue to increase in the coming decades. Impact is wide ranging: heart failure, stroke, dementia, etc. Long term success rates of ablation alone are suboptimal. Risk factor modification is proven to reduce A fib burden and to significantly improve outcomes in patients with A fib. \ Anticoagulants are recommended for those with 1 2 risk factors. Risks and benefits of new anticoagulants may be overstated. Idarucizumab is commercially available for reversing dabigatran. Andexanet alpha is safe and effective for reversing effects of apixaban and rivaroxaban. Watchman is FDA approved for LAA closure. Its place in AF management for the majority of AF patients remains uncertain. Thank You! michael.curley@wfhc.org 9