Transcript Heart Failure Then and Now

Atrial Fibrillation
Evidence Based Care
2011
Allan Anderson, MD, FACC, FAHA
Division of Cardiology
Projection for Prevalence of
Atrial Fibrillation: 5.6 Million by 2050
Adults with atrial fibrillation
in millions
Projected number of adults with atrial fibrillation in the United States between 1995 and 2050
7.0
6.0
5.16
5.0
5.42
5.61
4.78
4.34
4.0
3.80
3.33
3.0
2.26
2.08
2.0
2.44
2.66
2.94
Upper and lower curves represent the upper and lower scenarios based on sensitivity analyses.
1.0
0
1990
1995
2000
2005
2010
2015
2020
2025
2030
Years
Go AS et al. JAMA. 2001;285:2370-2375.
2035
2040
2045
2050
Cumulative mortality over 3 years (%)
Atrial Fibrillation Is Associated
With Increased Mortality
80
With atrial fibrillation
Without atrial fibrillation
70
65.1*
60
54.5
47.4*
50
40
30
71.3
38.6
51.0*
47.5
36.1*
34.0
30.2*
62.4
25.4*
20
10
0
65-74 years of age
75-84 years of age
* Significantly different from patients with atrial fibrillation (P<.05).
Wolf PA et al. Arch Intern Med. 1998;158:229-234.
85-89 years of age
Atrial Fibrillation:
Major Cause of Stroke in the
United States
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15% of all strokes attributable to atrial fibrillation
75,000 strokes per year attributable to
atrial fibrillation
3- to 5-fold increase in risk of stroke in patients with
atrial fibrillation
Stroke risk persists even in asymptomatic
atrial fibrillation
Go AS et al. JAMA. 2001;285:2370-2375; Go AS. Am J Geriatr Cardiol. 2005;14:56-61; Wolf PA et
al. Stroke. 1991;22:983-988; Benjamin EJ et al. Circulation. 1998;98:946-952; Page RL et al.
Circulation. 2003;107:1141-1145.
Increasing Hospitalizations in the United States
When Atrial Fibrillation Is Principal Diagnosis
Prevalence per 10,000 persons
(National Hospital Discharge Survey)
140
120
100
80
60
40
20
0
1985
1987
1989
1991
1993
1995
1997
1999
Year
Age (years)
85+
75 to 84
65 to 74
Wattigney WA et al. Circulation. 2003;108:711-716.
55 to 64
35 to 54
Atrial Fibrillation Adversely Affects
Quality of Life (QoL)
120 Lower scores = poorer QoL
100
80
Atrial fibrillation
92
88
85
SF-36 score
78
68
60
54
70
71
76
81
68
Post myocardial
infarction
Controls
59
40
20
0
General health
Physical
function
Social function Mental health
Dorian P et al. J Am Coll Cardiol. 2000;36:1303-1309.
Famous Fibrillators
Famous Fibrillators
Famous Fibrillators
Famous Fibrillators
Famous Fibrillators
Famous Fibrillators
Famous Fibrillators
Atrial Fibrillation
2011
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Patterns of AF
Evaluation of Patient
Evidence Base
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Rate Management
Rhythm Management
Prevention of thromboembolism
New stuff
Patterns of Atrial Fibrillation
First Detected
Paroxysmal
(Self terminating)
Persistent
(Non self terminating)
Permanent
Fuster, V. et al. J Am Coll Cardiol 2011;57:e101-e198
Atrial Fibrillation
Evaluation of Patients
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History and physical examination
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Presence and nature of associated symptoms
Clinical type (1st episode, paroxysmal, persistent,
permanent)
Onset/date of discovery of 1st episode
Frequency, duration, precipitating factors, mode of
termination
Response to therapies
Establish underlying heart disease or other
treatable conditions (e.g., hyperthyroidism,
alcohol)
Atrial Fibrillation
Evaluation of Patients
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ECG
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Verify rhythm
LVH?
Pre-excitation (WPW)?
Bundle branch block?
Prior MI?
Measure and follow intervals (R-R, QRS,
QT) in conjunction with drug therapy
Atrial Fibrillation
Evaluation of Patients
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Transthoracic echocardiogram
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Valvular disease
Chamber sizes/ventricular function
Peak RV systolic pressure (pulmonary hypertension)
LVH
Pericardial disease
Atrial clot (usually not helpful, requires TEE)
Atrial Fibrillation
Evaluation of Patients
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Other studies
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6 minute walk test: evaluate adequacy of rate control
Stress test
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Holter monitor
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Adequacy of rate control
Reproduce exercise-induced AF
Presence of ischemia (regarding use of IC drugs)
Verify/establish diagnosis
Adequacy of rate and/or rhythm control
Transesophageal echocardiogram (TEE)
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LA clot
Guide to cardioversion (expedited)
The Guidelines
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Class I: Conditions for which there is evidence and/or general
agreement that a given procedure/therapy is beneficial, useful,
and effective.
Class II: Conditions for which there is conflicting evidence
and/or a divergence of opinion about the usefulness/efficacy of
performing the procedure/therapy.
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IIA: Weight of evidence/opinion is in favor of usefulness/efficacy.
IIB: Usefulness/efficacy is less well established by
evidence/opinion.
Class III: Conditions for which there is evidence and/or general
agreement that a procedure/therapy is not useful or effective
and in some cases may be harmful.
Level of Evidence
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A: Data derived from multiple randomized
clinical trials or meta-analyses.
B: Data derived from a single randomized
trial, or nonrandomized studies.
C: Only consensus opinion of experts, case
studies, or standard-of-care.
Expert Opinion
One who knows
enough jargon to
be both
confusing and
dangerous.
Ambrose Bierce
1842-1913
Consensus
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General agreement within a group,
especially after protracted, lengthy,
bitter debate and loss of life.
Opinion obtained by straw polling
when the opposition is not present.
See team building.
The current thinking of the team
supervisor.
Rate or Rhythm Control?
Comparison of Trials
Rate vs. Rhythm Control
Clinical Events
Stroke/Embolism
Trial
Patients
(n)
AF
Duration
Patients
in SR *
NR
Death
Rate
Rhythm
Rate
Rhythm
35% vs.
63% (at
5 y)
88/2027
93/2033
310/2027
356/2033
AFFIRM
4060
RACE
(2002)
522
1 to 399 d
10% vs.
39% (at
2.3 y)
7/256
16/266
18/256
18/266
PIAF
(2000)
252
7 to 360 d
10% vs.
56% (at
1 y)
0/125
2/127
2/125
2/127
STAF
(2003)
200
6±3 mo
11% vs.
26% (at
2 y)
2/100
5/100
8/100
4/100
HOT
CAFÉ
(2004)
205
7 to 730 d
NR vs.
64%
1/101
3/104
1/101
3/104
(2002)
Rate Control Efficacy in Permanent Atrial
Fibrillation: a Comparison between Lenient
versus Strict Rate Control II
RACE II
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614 patients with permanent AF (age </= 80)
Lenient rate control (HR<110 at rest) OR
Strict rate control
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HR < 80 at rest, AND
HR < 110 during moderate exercise
Composite outcome: CV death, hospitalization
for HF, systemic embolism, bleeding, lifethreatening arrhythmia
Follow-up: At least 2 years; maximum – 3
years
Van Gelder IC, Groenveld HF, Crijns HJ, et al. N Engl J
Med 2010;362:1363-1373.
Rate Control Efficacy in Permanent Atrial
Fibrillation: a Comparison between Lenient
versus Strict Rate Control II
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RACE II
3 year cumulative incidence of primary
outcome
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P < 0.001
Target HR goal(s)
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12.9% - lenient
14.9% - strict
304 (97.7%) – lenient
204 (67%) – strict
P < 0.001
Total Visits
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75 – lenient
684 - strict
P < 0.001
Van Gelder IC, Groenveld HF, Crijns HJ, et al.
N Engl J Med 2010;362:1363-1373.
Atrial Fibrillation
The “Thou Shalt’s”
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Pharmacologic Rate Control (Class I)
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Measurement of the heart rate at rest
and control of the rate using
pharmacological agents (either a beta
blocker or non-dihydropyridine calcium
channel antagonist, in most cases) are
recommended for patients with persistent
or permanent AF. (Level of Evidence: B)
Atrial Fibrillation
The “Thou Shalt’s”
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Pharmacologic Rate Control (Class I)
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In the absence of pre-excitation, intravenous
administration of beta blockers (esmolol,
metoprolol, or propranolol) or nondihydropyridine calcium channel antagonists
(verapamil, diltiazem) is recommended to slow
the ventricular response to AF in the acute
setting, exercising caution in patients with
hypotension or HF. (Level of Evidence: B)
Atrial Fibrillation
The “Thou Shalt’s”
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Pharmacologic Rate Control (Class I)
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Intravenous administration of digoxin or
amiodarone is recommended to control
the heart rate in patients with AF and
HF who do not have an accessory
pathway. (Level of Evidence: B)
Atrial Fibrillation
The “Thou Shalt’s”
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Pharmacologic Rate Control (Class I)
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In patients who experience symptoms
related to AF during activity, the
adequacy of heart rate control should be
assessed during exercise, adjusting
pharmacological treatment as necessary
to keep the rate in the physiological
range. (Level of Evidence: C)
Atrial Fibrillation
The “Thou Shalt’s”
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Pharmacologic Rate Control (Class I)
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Digoxin is effective following oral
administration to control the heart rate
at rest in patients with AF and is
indicated for patients with HF, LV
dysfunction, or for sedentary individuals.
(Level of Evidence: C)
Atrial Fibrillation
The “Thou Shalt Not’s”
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Pharmacologic Rate Control (Class III)
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Digitalis should not be used as the sole agent to
control the rate of ventricular response in
patients with paroxysmal AF. (Level of
Evidence: B)
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Catheter ablation of the AV node should not be
attempted without a prior trial of medication to
control the ventricular rate in patients with AF.
(Level of Evidence: C)
Atrial Fibrillation
The “Thou Shalt Not’s”
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Pharmacologic Rate Control (Class III)
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In patients with decompensated HF and AF, intravenous
administration of a non-dihydropyridine calcium channel
antagonist may exacerbate hemodynamic compromise and
is not recommended. (Level of Evidence: C)
Intravenous administration of digitalis glycosides or nondihydropyridine calcium channel antagonists to patients
with AF and a pre-excitation syndrome may paradoxically
accelerate the ventricular response and is not
recommended. (Level of Evidence: C)
Therapy to maintain sinus rhythm in patients
with recurrent paroxysmal or persistent atrial fibrillation
Wann, L. S. et al. J Am Coll Cardiol 2011;57:223-242
Atrial Fibrillation
The “Thou Shalt’s”
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Maintenance of sinus rhythm (Class I)
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Before initiating anti-arrhythmic drug
therapy, treatment of precipitating or
reversible causes of AF is recommended.
(Level of Evidence: C)
Atrial Fibrillation
The “Thou Shalt Not’s”
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Maintenance of sinus rhythm (Class III)
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Antiarrhythmic therapy with a particular drug is not
recommended for maintenance of sinus rhythm in patients
with AF who have well-defined risk factors for
proarrhythmia with that agent. (Level of Evidence: A)
Pharmacological therapy is not recommended for
maintenance of sinus rhythm in patients with advanced
sinus node disease or AV node dysfunction unless they
have a functioning electronic cardiac pacemaker. (Level of
Evidence: C)
Prevention of
Thromboembolism
Effects on all stroke (ischemic and
hemorrhagic) of therapies for patients with
atrial fibrillation
Stroke Risk Prediction in AF
CHADS2 Criteria
CRITERIA
SCORE
Prior stroke or TIA
2
Age > 75 years
1
Hypertension
1
Diabetes Mellitus
1
Heart Failure
1
Walraven WC et al. JAMA 2001;285:2864–70 (426).
Stroke Risk Prediction in AF
CHADS2 Criteria
Patients
Adjusted stroke
rate/yr with 95% CI
CHADS2 Score
1733
120
1.9 (1.2 -3.0)
463
2.8 (2.0-3.8)
523
4.0 (3.1-5.1)
337
5.9 (4.6-7.3)
220
8.5 (6.3-11.1)
65
12.5 (8.5-17.5)
5
18.2 (10.5 – 27.4)
Walraven WC et al. JAMA 2001;285:2864–70 (426).
0
1
2
3
4
5
6
Atrial Fibrillation
The “Thou Shalt’s”
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Prevention of thromboembolism (Class I)
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Antithrombotic therapy to prevent
thromboembolism is recommended for all
patients with AF, except those with lone AF or
contraindications. (Level of Evidence: A)
The selection of the antithrombotic agent should
be based upon the absolute risks of stroke and
bleeding and the relative risk and benefit for a
given patient. (Level of Evidence: A)
Atrial Fibrillation
The “Thou Shalt’s”
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Prevention of thromboembolism (Class I)
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For patients without mechanical heart valves at high risk of
stroke, chronic oral anticoagulant therapy with a vitamin K
antagonist is recommended in a dose adjusted to achieve the
target intensity INR of 2.0 to 3.0, unless contraindicated.
Factors associated with highest risk for stroke in patients with
AF are prior thromboembolism (stroke, TIA, or systemic
embolism) and rheumatic mitral stenosis. (Level of Evidence: A)
Anticoagulation with a vitamin K antagonist is recommended for
patients with more than 1 moderate risk factor. Such factors
include age 75 y or greater, hypertension, HF, impaired LV
systolic function (ejection fraction 35% or less or fractional
shortening less than 25%), and diabetes mellitus. (Level of
Evidence: A)
Atrial Fibrillation
The “Thou Shalt’s”
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Prevention of thromboembolism (Class I)
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INR should be determined at least weekly during initiation of therapy
and monthly when anticoagulation is stable. (Level of Evidence: A)
Aspirin, 81–325 mg daily, is recommended as an alternative to vitamin K
antagonists in low-risk patients or in those with contraindications to oral
anticoagulation. (Level of Evidence: A)
For patients with AF who have mechanical heart valves, the target
intensity of anticoagulation should be based on the type of prosthesis,
maintaining an INR of at least 2.5. (Level of Evidence: B)
Antithrombotic therapy is recommended for patients with atrial flutter
as for those with AF. (Level of Evidence: C)
Atrial Fibrillation
The “Thou Shalt Not’s”
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Prevention of thromboembolism (Class
III)
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Long-term anticoagulation with a vitamin
K antagonist is not recommended for
primary prevention of stroke in patients
below the age of 60 y without heart
disease (lone AF) or any risk factors for
thromboembolism. (Level of Evidence: C)
Dabigatran (Pradaxa)
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Direct thrombin inhibitor
Dose:
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CrCl > 30: 150 mg twice daily
CrCl < 30: 75 mg twice daily
See prescribing information on
transitions between warfarin or
parenteral anticoagulants
Dabigatran (Pradaxa)
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1.5 % risk of life threatening bleeding
vs. 1.8% for warfarin (RE-LY)
Avoid with Rifampin (P-gp inducer)
Pregnancy Class C
Major side effects: bleeding;
gastrointestinal
Dabigatran versus Warfarin in Patients
with Atrial Fibrillation
RE-LY
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Non-inferiority trial
18,113 patients randomized
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110 or 150 mg dabigatran – blinded
Adjusted dose warfarin – unblinded
2.0 year median follow-up
Primary outcome: stroke or systemic
embolization
Connolly SJ, et al. N Engl J Med 2009; 361:1139-1151.
RE-LY
Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism
According to Treatment Group.
Connolly SJ et al. N Engl J Med 2009;361:1139-1151.
A Few Words About AF Ablation
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Increasingly effective procedure,
depending on type of AF
Paroxysmal > Persistent > Permanent
Failure of drug therapy or importance
of maintaining SR for hemodynamic
purposes
Not without risk – requires experience
Thank You!
Questions??