AF and arrhythmia management Dr Rhys Beynon Consultant Cardiologist and Electrophysiologist University Hospital of North Staffordshire
Atrial fibrillation Paroxysmal AF recurrent AF (>2 episodes) that terminates spontaneously within 7 days. Persistent AF AF requiring cardioversion Permanent AF
Triggers - PAF AF causes Substrate Permanent AF
AF investigations BP FBC, U&E, LFT, TFT, Glucose ECHO All patients under 75? Will echo alter management Anticoagulation? Structural heart disease 4
Options for management Paroxysmal AF Medication to prevent recurrences of AF Ablation. Persistent AF Medication to prevent recurrences of AF Ablation Permanent AF Medication to control the ventricular rate 5
AF rate control Beta blockers Calcium channel blockers Digoxin now second line therapy in addition to B blockers or CCB Target HR resting HR < 110 bpm If still symptomatic despite max medication ablate and pace Van Gelder, I.C., et al., Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med, 2010. 362(15): p. 1363-73. 6
Why bother trying to maintain sinus Rhythm? Prevent palpitations if PAF Improve quality of life Do people feel better in sinus rhythm than AF? Probably not if elderly Potentially if young? Reduce risk of CVA No conclusive randomised evidence that maintaining sinus rhythm reduces strokes or prolongs life lot of suggestive data 7
Medication to prevent AF Mildly effective Beta blockers Bisoprolol Calcium channel blockers Verapamil Moderately effective Sotalol not a typical B Blocker Flecainide Dronedarone Very effective Amiodarone 8
Risks of long term medication Minimal risk B blockers Calcium channel blockers Low risk Flecainide atrial flutter with 1:1 conduction (prescrible with B blockers), sudden death in ischaemic patients Sotalol polymorphic ventricular tachycardia Dronedarone Moderate/high risk Amiodarone Risks: Liver, lung, thyroid, skin, eye
Risk of Torsades de Pointes with sotalol Lehmann M H et al. Circulation 1996;94:2535-2541
Dronedarone New antiarrhythmic benzofuran class Similar to amiodarone but without the iodine Usual dose 400mg bd Cost 2 per day Similarly effective as Flecainide and sotalol Contraindicated in Class 3 and 4 heart failure and persistent AF Useful if unable to tolerate or take sotalol/flecainide 11
Dronedarone Monitoring: 6 monthly ECGs LFTs at 1/52, 1/12 and then monthly to 6 months then at 9 and 12 months. U&E baseline and 1/52 12
Atrial fibrillation ablation
RCT Drug treatment vs ablation Jaïs P et al. Circulation 2008;118:2498-2505 Hunter, R.J., et al., Maintenance of sinus rhythm with an ablation strategy in patients with atrial fibrillation is associated with a lower risk of stroke and death. Heart, 2012. 98(1): p. 48 53
RCT Drug treatment vs ablation Wilber, D. J., C. Pappone, et al. (2010). "Comparison of Antiarrhythmic Drug Therapy and Radiofrequency Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation." JAMA: The Journal of the American Medical Association 303(4): 333 340 Pappone, C., et al., A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study. J Am Coll Cardiol, 2006. 48(11): p. 2340 7. 15
Complications Hunter, R.J., et al., Maintenance of sinus rhythm with an ablation strategy in patients with atrial fibrillation is associated with a lower risk of stroke and death. Heart, 2012. 98(1): p. 48 53 16
Atrial fibrillation Ablation Factors affecting ablation success PAF vs Persistent Duration in AF LA size (diameter >5cm) Other structural lesions (MR/LV impairment) Ability to maintain sinus rhythm post cardioversion (amiodarone)
Atrial fibrillation ablation Benefits of ablation Multiple studies show that ablation is superior to medication in preventing AF and symptoms? Prognosis Catheter Ablation Versus Anti arrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA) RCT, 3000 patients, ablation vs medication both PAF and persistent AF Primary outcome: death Secondary outcomes: CVA, Hospitalisation, QOL Results expected 2015 Early treatment of Atrial fibrillation for Stroke prevention Trial (EAST) European RCT, Similar to CABANA,
Urgent referrals? AF with syncope or haemodynamic compromise Onset of symptoms <24 hours Associated TIA/Stroke 19
Referrals to secondary care PAF AF and structural heart disease Syncope Slow AF Symptomatic despite treatment Cardioversion 20
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