Fibs and Flutters: The Heart of the Matter Anita Ralstin, CNP By the Numbers Atrial Fibrillation Hospital Discharges /quarter for 2012 -- 116,500 Average Length of Stay 4 days Projected that 20% of those over 80 years have atrial fibrillation Prevalence: 2,000,000 US 1
What is Atrial Fibrillation? 2
What is Atrial Fibrillation? An irregular heart beat generated when the top chambers of the heart are beating very rapidly. Atrial fibrillation compromises several aspects of heart function. Rate Regularity of the heart rhythm Loss of loading the ventricle with blood Loss of the forceful atrial contraction slows blood flow in the top chambers of the heart. Are there different kinds? Paroxysmal (self-terminating)- sustained > 30 seconds Persistent (>7d)- requires shock to terminate Permanent- unable to convert except with surgery or ablation First detected episode vs. recurrent Secondary AF- pneumonia, heart surgery etc. Lone AF- no other heart disease 3
What causes Atrial Fibrillation? Triggers for Atrial fibrillation Triggers Pulmonary veins Account for ~70% of atrial fibrillation in men 60% in women Ganglionated plexi 20% Other thoracic veins 10% in both sexes Nonvenous locations LA Posterior wall, CS OS, Crista Terminalis Triggers elimination is curative. 4
Case 1 58 year old woman History of symptomatic bradycardia and PPM Device check shows 2 episodes of atrial fibrillation with ventricular rate to 188, longest duration; 2 hours 14 minutes Patient is asymptomatic History includes hypertension Current medication: Micardis Echo and stress of 1/2013 WNL 5
Goals of Therapy Prevent Stroke- appropriate anticoagulation Prevent CHF- rate control, HTN control Acute symptomatic CHF related to rate Chronic diastolic CHF in older patients Control symptoms What symptoms come from Atrial Fibrillation? Palpitations, chest pain Fatigue Shortness of breath with exertion Leg swelling Difficulty concentrating Difficulty sleeping Lightheadedness with change of position Fainting 6
Case 1 Type of atrial fibrillation? New onset, paroxysmal Concerns about rate or rhythm? HR of 188 Yet to determine burden What is her stroke risk? Replacing the CHADS2 score CHADS2 score- not everyone needs warfarin 2 points for prior stroke 1 point for congestive heart failure, high blood pressure, age >75 and diabetes. In most series 25-35% of the patients are in the indeterminate range Are low risk patients low risk? 2006 ACC/AHA Guidelines for atrial fibrillation management 7
CHA 2 DS 2 Vasc Score Congestive Heart Failure Hypertension Age>75 (2 points) DMII Prior Stroke (2 points) Age 65-74 Vascular disease (PVDz, aortic atheroma) Female Sex CHADS vs. CHA 2 DS 2 VASc 121,281 patients with nonvalvular Afib The critical area is the in the low and intermediate risk patients * * Oleson, JB et al, BMJ online first December 2010 :1-9. 8
CHA 2 DS 2 VASc is Superior Low risk CHADS2= 39% intermediate risk, 21% high risk (only 40% were low risk) by CHA 2 DS 2 VASc Intermedite CHADS2=93% at high risk CHA 2 DS 2 VASc not only predicted TE better but also mortality better C statistics for the low, intermediate and high for CHA 2 DS 2 VASc were much better. CHA 2 DS 2 VASc =0 no anticoagulation Oleson, JB et al, BMJ online first December 2010 :1-9. Case 1 What is her need for anticoagulation CHADS2 score = 1 (HTN) CHADS2Vasc = 2 (HTN and Gender) Also consider burden 3 hours or more when identified on device 9
Case 1 Plan Patient education What is atrial fibrillation Monitor for symptoms Address anxiety Rate Management Beta blocker, calcium channel blocker or digoxin Consider ejection fraction and side effects Anticoagulation: ASA 81 mg 162 mg (chewable) Will it get worse? Lone Atrial Fibrillation- rare No evidence that it will progress Paroxysmal atrial fibrillation 15%/year progress to persistent atrial fibrillation More heart disease means more likely to progress Progression generally means more symptoms Older, sicker patients move towards more atrial fibrillation. 10
Case 2 60 year old male New onset atrial fibrillation with shoulder surgery Onset documented with hospitalization. Symptomatic with rapid ventricular rate (RVR): hypotensive PMH Hypertension Gout Barrets Esophagus Smoker Obese Atrial Scarring Injury to the heart muscle Age High blood pressure Structural problems in the heart Heart attacks, valve problems, congestive heart failure Sleep apnea Obesity Alcohol Repeated exercise All of these lead to fibrosis 11
Case 2 Diagnostic Echocardiogram: Normal EF, Moderate left atrial enlargement Lab work: no significant abnormals Case 2 Hospital Treatment EP consult Rate control Diltiazem drip Hypotension IV metoprolol Short acting Digoxin load Consider renal function 12
Case 2 Contd Rhythm Control: Hospital If unstable and known duration of <48 hours Synchronized cardioversion If unstable and unknown duration TEE and cardioversion Antiarrhythmic Amiodarone drip to PO Case 2 Still in the Hospital Anticoagulation CHADS Vas score = 1 (HTN) Heparin to warfarin initiated Cardioversion results in atrial stunning and increases risk of thrombus early post CV 13
Case 2 Office Visit Presented complaining of fatigue, irregular HR, generally not feeling well ECG shows recurrent atrial fibrillation, rate 95 on diltiazem Anticoagulation has been stable INR goal for atrial fibrillation 2.0-3.0 Why does it keep going? 14
Case 2 Type of atrial fibrillation: Recurrent, persistent Treatment goals: Rate control (goal 80-110) Symptom goal Rhythm goal Adding Antiarrhythmic Therapy AAD for Rhythm Control Amiodarone SE makes less desirable for younger pts: monitor thyroid, liver and pulmonary Dronedarone Avoid with HF Flecainide Not with structural heart disease Propafenone Renal dosing; hospital start Sotalol Hospital start 15
Case 2 Normal structural heart Flecainide 50 mg BID Continue anticoagulation Consider atrial fibrosis Add spironolactone Evaluate for sleep apnea Sleep Apnea Sleep Heart Health Study 2800 patients Took PSGs from the patients with afib and performed case control analysis Matched sleep stages, no PVCs and no pauses Used the entire group to estimate total event rates 62 total arrhythmic periods were found Afib and NSVT were the most common Monahan, K, et al. JACC 2009 16
Mankopf,C, HRS 2010 Case 2 Next Visit Return visit Ongoing similar symptoms of fatigue and palpitations ECG shows persistent atrial fibrillation Options Repeat cardioversion Change AAD Consider pulmonary vein ablation 17
Atrial Fibrillation Ablation Atrial fibrillation ablation right now CT scan of the chest beforehand 4 hours under general anesthesia 1 night in the hospital Coumadin 1 month before and 3 months afterwards 80-85% cure rate requires >1 procedure 10% of the time. Complication rate 10% (mostly minor) Bleeding/perforation 3% usually managed with a drain Stroke 0.2% Esophageal injury 0.1% Death 0.1% 18
Case 3 88 year old female referred by PCP for atrial fibrillation found on ECG, HR 55 BPM History Mild dementia; diabetes, hypertension, recent fall and hip fracture Symptoms Fatigue, increased confusion, edema and shortness of breath Case 3 Diagnostic Echocardiogram shows LV EF 25-30% with bi-atrial enlargement Lab: renal insufficiency and anemia 19
Case 3 Treatment Goals Rate control Has underlying conduction issues if rate in the 50s not on any rate control meds Rhythm control Is this reasonable? Could she be cardioverted? Anticoagulation Assessing Bleeding Risk HAS-BLED" 1 point for each Hypertension Abnormal Liver/Renal Function Stroke History Bleeding Predisposition Labile INRs "Elderly" (Age >e; 65) (fall risk) Drugs/Alcohol Usage 20
Case 3 Treatment Plan Rate control PPM +/- AV node ablation Rhythm management Not appropriate Anticoagulation ASA 81 mg daily Vitamin D and Afib 30-50% of the Americans are Vitamin D deficient Retrospective study of patients. Vitamin D deficient patients slightly less likely to have atrial fibrillation (OR=0.83) More likely to have HTN, DMII (OR=1.4, 2.31). CAD/CM more likely (OR= 1.16, 1.4) Howard, PA et al, AJC, 109:359-363, 2012 21
Atrial Flutter Atrial Flutter Regular arrhythmia Flutter waves visible (CL 200-280ms) V1- isoelectric component III and avf- downward continous Difficult to rate control Usually sustained until intervention (stable arrhythmia) Pulmonary disease (DDimer) Sleep apnea 22
Atrial Flutter Ablation Even in the elderly 95% success rate 1/500 minor complication Fewer medications, fewer readmissions, less CHF VERY IMPORTANT Atrial fibrillation occurs in 40-50% of these patients over 5 years. Slow to stop warfarin even though AFL cured Atrial Flutter Typical Flutter waves visible (CL 200-280ms) V1- isoelectric component III and avf- downward continuous Atypical Flutter waves visible, but not typical morphology Usually have had prior heart surgery or atrial ablation 23
Rely; Rocket AF; Aristotle New anticoagulants show equivalency or superiority compared head to head with warfarin for nonvalvular Afib. Dabigatran- Rely Rivaroxaban- Rocket AF Apixaban- Aristotle Trial Data Major Results of Phase 3 Trials of New Anticoagulants vs Warfarin in AF Drug/Trial Efficacy: Stroke/ Thromboembolism Hemorrhagic Stroke Major Bleeding Dabigatran in RE-LY 34% reduction 74% reduction Similar Rivaroxaban in ROCKET Noninferior to warfarin 40% reduction Similar Apixaban in ARISOTLE 20% reduction 50% reduction 30% reduction 24
Dabigatran Dabigatran- oral prodrug converted to active agent by serum esterase Competitively blocks thrombin 12-17 hour half life Cleared by the kidneys 80% FDA APPROVED EARLY DEC 2010. Conolly,SJ, NEJM Sept 2009 Dabigatran Bottom line Useful for plain old Afib 40% less strokes No INR testing Fast onset, fast offset (hold for 2 days) 10% have GI distress Difficult to reverse Expensive ($40 to $240/month) Not safe for continuation through procedures Interacts with multiple medications? Safe in patient with CAD 25
Rivaroxaban Oral once daily direct factor Xa inhibitor Lovenox and fractionated heparins Peak effect is 4 hours after a dose Half life is 8-12 hours but Xa is inhibited for 24 hours allowing 1x daily dosing CYP3A4 dependent metabolism, 2/3 hepatically eliminated Accumulates CrCl<50. Rivaroxaban Bottom Line Proven safe in high CHADS2 patients Once daily Proven safe in ACS and PE Fast onset and offset Cost. 26
Apixaban The recommended dose is 5 mg orally twice daily. In patients with at least 2 of the following characteristics: age 80 years, bodyweight 60 kg, or serum creatinine 1.5 mg/dl, the recommended dose is 2.5 mgorally twice daily. a factor Xa inhibitor anticoagulant indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Apixaban New to the market Same indications Fewer SE BID dosing Renal dosing Cost 27
Nurse Practitioner 28