Practical Approaches to Atrial Fibrillation Management Answers to Your Everyday Questions H. Mark Guo, MD, FACC, FHRS Clinical Cardiac Electrophysiology Oregon Heart & Vascular Institute hguo@peacehealth.org
Disclosure SYSTEMS OF CARE SYMPOSIUM 2015 Care of Your Patient in the Era of Population Health Hongsheng Mark Guo, MD, FACC, FHRS I use free pens from all industrials. I have no other financial relationships to disclose.
Thursday 8 am: 63 yo man calls from MSP In AF at least since Tuesday morning Had breakfast in Indianapolis at 5:00am Flight changed to 7:00pm to continue trip Insists on not delaying trip any later Previous episode in 5/2004 (metoprolol and propafenone) Cardioversion scheduled 4:00pm
ECG @ 9:40 am 4/26/07
What would you do? A. Cardioverte and catch flight B. Cancel cardioversion, titrate BB, start coumadine, cardioverte after trip C. Cardioverte, start lovenox and coumadine, f/u with ACC D. Cancel cardioversion, titrate BB, start coumadine, ablation after 3-4 weeks AC E. Start NOAC, TEE, cardioverte if no clot
What is AF? AF is the most common sustained arrhythmia. Prevalence: 0.4% to 1% in general population, increasing with age to 12% for those > 75 yrs. Stroke rate: < 1% to > 15% annually, depending on comorbid risk factors.
Atrial Fibrillation Is Common
Atrial Fibrillation Demographics by Age U.S. population x 1000 Population with AF x 1000 30,000 20,000 U.S. population Population with atrial fibrillation 500 400 300 10,000 200 100 0 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 >95 0 Age, yr Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.
What is the Pathophysiology of AF? AF may be triggered by a focal source of rapid atrial electrical depolarization, often in the pulmonary veins. It is sustained by the presence of multiple reentrant wavelets or spiral wave reentrant circuits (rotors). Theories (Too Simple to be perfect) Wishes and dreams. Clueless!
What causes my AF? Acute and temporary causes (triggers) alcohol intake (holiday heart) surgery (particularly cardiac surgery) MI, pericarditis, myocarditis, CHF pulmonary embolism hyperthyroidism. Concurrent treatment of the underlying disorder and management of AF
Other Causes of AF Triggered by other arrhythmias atrial tachycardia atrial flutter Wolff-Parkinson-White (WPW) syndrome AV nodal reentrant tachycardia. Associated with chronic disorders sleep apnea hypertension obesity
How to establish an accurate diagnosis of AF? Symptoms maybe absent Not Reliable Irregularly irregular rhythm ECG 12-lead Ambulatory: Holter, Event monitor, ILR Device interrogation Should be distinguished from atrial flutter, multifocal atrial tachycardia reentrant SVTs, such as AV nodal reentry; sinus rhythm (SR) with multiple premature atrial complexes.
Are all AFs the same? Paroxysmal terminates spontaneously within 7 days of onset Persistent sustained > 7 days longstanding persistent: continuous AF > 12 months duration. Permanent Lone AF
Are all AFs treated in the same way? Hemodynamically unstable: Immediate cardioversion, sedate if possible Refractory, IV amiodarone, ibutilide, or procainamide. Hemodynamically stable: Cardioversion: newly diagnosed, onset within 48 hours Rate control, anticoagulation if indicated Cardioversion after 3-4 weeks anticoagulation or no clot on TEE and therapeutic anticoagulation initiated.
Case 72 yo woman, POD #1 (Ovarian mass removal), ECG shows AF HR 100-120 bpm, BP 158/66, R 18 PMH: HTN, and CAD with LCx stented 5 yr ago What would be your most appropriate next step: A. Cardioversion B. Aspirin C. Warfarin/NOAC D. Metoprolol E. TEE
CASE TEE is performed. Most likely result you predicted is: A. LAA thrombus B. Spontaneous echo contrast (smoke) in LA C. Clear LAA D. Annual stroke risk is 1-2% E. Annual stroke risk is 3-5% F. Annual stroke risk is 5-9%
CHA 2 DS 2 -VASc Risk factor score C Congestive heart failure/lv dysfunction 1 H Hypertension 1 A2 Age 75y 2 D Diabetes mellitus 1 S2 Stroke/TIA/TE 2 V Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1 A Age 65-74y 1 Sc Sex category (ie female gender) 1 Maximum Score 9 maximum score is 9 since age may contrubute 0, 1, or 2 points Lip GY, et al., Chest 137, 263-272, 2010
CHA 2 DS 2 -VASc overall event rates %/year 6 Stroke and systemic embolism 5 4 3 2 1 0 CHA 2 DS 2 -VASc 0-1 2 3 4 5 6 7 8-9 No of patients 634 3408 5365 4378 2566 1185 451 125
Marine JE. JAMA. 2007; 298(23): 2368-2778
Cryoballoon
Atrial Fibrillation Ablation: Success & Repeat Procedures 50 70% success with a single procedure Up to 50% will require a second procedure to achieve success 50% will have early recurrence within the first couple days to weeks 50% of these will resolve within few weeks and still have success
Atrial Fibrillation Ablation: Long Term Outcome Free of antiarrhythmic drugs and free of arrhythmia symptoms at 6 months Paroxysmal 70 to 90% Persistent (lasts > 7 days, up to 1 year) 60 to 80% Long standing persistent (> 1 year) 50 to 70%
Atrial Fibrillation Ablation: What are the risks? Major: (overall risk < 1%) Stroke (0.2%) Heart attack (< 0.02%) Atrial-esophageal fistula (rare 0.02%) Death (0.1%) Intermediate: Pulmonary vein narrowing or stenosis (0.3%) Bleeding around the heart or tamponade (1.0%) Diaphragm paralysis (0.2%) Need for a pacemaker (rare - < 0.02%) Minor: Groin site bleeding or hematoma (1-3%) Infection (0.01%) *Second Worldwide Survey on the Efficacy and Safety of Catheter Ablation for Atrial Fibrillation
Atrioesophageal Fistula
Catheter Ablation: How Is A Cure Delivered? Conventional Better understanding of mechanism Fixed circuits or foci Target: substrate Atrial flutter AVNRT WPW Focal atrial tachycardia VT AF Ablation Mechanism? Microreentry Multiple wavefronts No fixed circuit Triggers Target(s): Triggers? Drivers? Substrate? Autonomic nerves?
What Is EP? Exquisiteness Elegance Delicacy 高雅 精巧 精致优雅 Precision Perfection Cure Satisfaction 精确 完美
What Is EP? Massiveness 粗糙 Nastiness 邋遢 Reckless 鲁莽 Excessiveness 多余 Destructiveness 毁坏 Exquisiteness Elegance Delicacy Precision Perfection Cure Satisfaction Deviating
When to offer a therapy as first-line? Safety Effectiveness Need from patient
AF Ablation Summary AF ablation is an AF ablation, still. There are many uncertainties. More data is needed. It is still too early to be offered to most patients as a first-line therapy. Catheter ablation might be the right answer for some patients.
Priority of Care Rate Control Anticoagualtion Rhythm Control
2/15/06, ER: 58 yo Man, Day Before EPS
Before (12/23/05 08:47:00) After (02/16/06 15:50:55)
What s New in 2015? Stroke risk assessment: CHA 2 DS 2 -VASc New oral anticoagulants: Dabigatran Rivaroxaban Apixaban Edoxaban Ablation: targeting substrates Digoxin: associated with worse outcome
Stroke Prevention in 2015
Digoxin is associated with bad outcomes
Sinus Rhythm, Not AAD Use, Is Associated With Improved Survival The AFFIRM Investigators. Circulation. 2004;109:1509-1513.
AF Ablation in 2015 Targeting Substrates
Atrial Fibrosis Is Associated With AF Recurrence
Summary AF is common, with different clinical presentations. AF is a complicated arrhythmia and our understanding regarding the exact mechanism remains limited. Catheter ablation, although based on imperfect theory, may help selected patients. AF is a manageable arrhythmia, and options are available for all patients to minimize risks for complications and to improve quality of life.
References Questions? 541-600-4GUO hguo@heacehealth.org