Transcript Rate or rhythm control for the patient twith atrial fibrillation?

Atrial Fibrillation Rate vs Rhythm control
Which is better ?
Dwayne Campbell, MD
Disclosure
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Medtronic
Milestone Pharmaceuticals, Inc.
National Institutes of Health
Employee-Iowa Heart Center/Mercy-Des Moines
Objective
• Review goals of Atrial fibrillation management
• Compare rate vs rhythm control management
Strategy in achieving those goals
• Review current guidelines for afib management
Epidemiology and Prognosis
• Most common arrhythmia
• >80% of individuals are > 65yo
• 1/3 of hospitalizations for
arrhythmias
• 2.3 million people in North
America
• 70,000 strokes/yr due to AF
• 1990 – 2005 admissions
increased 66%
• $1 billion spent yearly on postop AF
JACC 2004; 43:1001-1003
Mortality and AF
Am J Cardiol 2001; 87:346
Classification
• Paroxysmal
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Spontaneous termination
Last < 7 days
Usually < 48 hrs
• Persistent
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No spontaneous termination
Lasting > 7 days
• Long- Standing persistent
• >12 months
• Non valvular
• >AF in the absence of rheumatic mitral stenosis, a
mechanical or bio prosthetic heart valve, or mitral
valve repair
Management strategy
• Rate control
– HR control with no commitment to restore NSR
• Drugs or pacer
• Rhythm control
• Attempt restoration and maintenance of NSR
• cardioversion or catheter ablation
• Both strategies require anticoagulation to prevent
thromboembolism
CHA2DS2-VASc Score
Risk factor
Score
Congestive heart failure/LV
1
Hypertension
1
Age ≥75 years
2
Diabetes mellitus
1
Stroke/TIA/thromboembolism
2
Vascular disease
1
Age 65-74 years
1
Sex category (ie, female sex)
1
Maximum score
9
* Prior MI, PAD, aortic plaque. Actual rates of stroke in contemporary cohorts may vary
from these estimates
Camm AJ et al: Eur Heart J 2010;31:2369-2429
Ultimate Goal of Management
• Improve Mortality /Morbidity
• Decrease incidence of of Thromboembolic events
• Improve quality of life
•4060 patients - randomized to rate or rhythm control strategies
•Digoxin, calcium channel blocker, and/or beta-blocker were used
for rate control(2027 patients)
•Electrical cardioversions, class IA, IC, and III drugs to rhythm-control
arm (2033 )
•Oral anticoagulation adjusted to maintain INR of 2.0 to 3.0
•Could be stopped if sinus rhythm > 4 weeks
AFFIRM Trial
P 0.08
Major trials comparing rhythm to rate
controls
• PIAF-Pharmacological Intervention in Atrial Fibrillation (2000)
• STAF - Strategies of Treatment of Atrial Fibrillation study(2003)
• RACE-Rate Control vs Electrical cardioversion for persistent AF(2002)
• AFFIRM-AF follow–up investigation of rhythm management (2002)
• HOT CAFÉ- - How to Treat Chronic Atrial Fibrillation(2004)
• AF CHF-Atrial Fibrillation and Congestive Heart Failure(2007)
• J RHYTHM- Japanese Rhythm Management Trial for AF(2009)
Mortality
de Denus et al. Arch intern Med. 2005;185:258
Thomboembolic Events
de Denus et al. Arch intern Med. 2005;185:258
Quality of Life Measures
Singh et al. J Am Coll Cardiol 2008;48:721-30
“Nature has equipped the human heart with a complex
electrical system for the purpose of coordinated
propulsion of blood under a variety of physiologic
conditions. Considerable effort is expended by the heart
to maintain sinus rhythm. Cardiac
electrophysiologists…are frustrated by the conundrum
that atrial fibrillation is associated with increased
morbidity and mortality, yet attempts to prove that a
strategy to maintain nature’s rhythm has a favorable
effect on patients have been met with one setback after
another.
Cain ME. Rhythm control in atrial fibrillation—one setback after another
New Engl J Med. 2008;258-2725-
So why no difference between
strategies ?
• limitations of anti-arrhythmic drugs
• all proarrythmic(increase mortality with SHD
• end organ toxicity
• poor long term efficacy
• treatment palliative not curative
• subjective adverse events
• limitations of the trials
Major trials comparing rhythm to rate controls
Rhythm controlled preferred
• Persistent symptoms despite rate controls
• Inability to maintain adequate rate controls
• First episode of atrial fibrillation
• Younger patients
• Sign symptoms of left ventricular dysfunction
• Patient preference
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
Rhythm Control Strategy
. T. January et al. Circulation. 2014;130:e199-e267
Craig
PAF – 198 patients
JACC 2006; 48 (11):2340-2347
Rate control preferred
• AF duration > one year
• Increased left atrial size>4.5cm
• Underlying cause of AF that has not been treated
• Age >65y
• Patient preference
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
Rate control strategy
Craig T. January et al. Circulation. 2014;130:e199-e267
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Adequate rate control
HR<110 at rest
Conclusion
• Due to limitation of current medical therapy a rate
control strategy has not been shown to be inferior to
a rhythm control strategy
• Unclear what is the best option is for younger
patients
• Ablation is more effective in maintaining NSR than
AAD but Data on whether or not this translates to
improved mortality is Pending (CABANA Trial)
Management
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Rate control
Prevention of thromboembolism
Conversion to NSR – always try
Management
– Pattern of presentation – persistent, paroxysmal,
permanent
• Underlying conditions
• Restoration and maintenance of NSR
• HR control and anticoagulation
Kaplan-Meier estimates of the cumulative incidence of the primary outcome
(composite of: death from cardiovascular causes, hospitalization for heart failure,
and stroke, systemic embolism, bleeding, and life-threatening arrhythmic events)
comparing strict versus lenient rate control
Who Gets AF?
• Both genders get AF but it is more dangerous for women
• Men with AF have 1.5 times greater risk of death than men
without AF
• Women with AF have 1.9 x greater risk of death than women
without AF
• Structural heart disease, age, DM, CHF, HTN, OSA, COPD, TSH,
familial, CAD
Circulation 1998; 98 (10): 946-52
Impact of OSA on Atrial Fibrillation
Atrial Fibrillation
Definition
• Atrial fibrillation (AF) is an atrial tachyarrhythmia
• Uncoordinated atrial activation with lack of atrial
mechanical function
• AF impulses usually generate in the atria and in the
pulmonary veins