Transcript Pacers to the Max

Atrial Fibrillation: New Ways
to Treat an Old Rhythm
Disclosures: None
Objectives
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Scope of atrial fibrillation problem?
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Stroke Risk Reduction.
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Oral anticoagulation*.
Device options*.
Rate vs. Rhythm Control.
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General information.
Negative effects?
Rate Control*.
Rhythm Control.
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Cardioversion.
Medications*.
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Ablation*.
Practical Management.
*: “New Treatments”
Epidemiology and
Prognosis
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Most common sustained arrhythmia
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2.2 million in US
Last 20 years, 66% increase in admissions for a-fib
0.4-1% prevalence (up to 8% in those older than 80)
Incidence:
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0.1% per year <40 y/o
1.5-2% per year >80 y/o
Prognosis:
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Increased risk of stroke (5-fold).
Increased risk of heart failure (3-fold).
Double mortality rate.
Diminished quality of life.
Possible increased risk of dementia.
Dementia Risk
 AF indepenently associated with all forms of dementia
 37025 consecutive patients from large database followed
prospectively.
 10161 (27%) developed AF
 1535 (4.1%) developed dementia
 5 years follow-up.
 Mean age 60.6±17.9 years
Dementia Risk cont.
 AF independently associated
with all dementia.
 Highest risk of AD was in
younger AF group
 Dementia patients had higher
rates of HTN, CAD, CRI,
heart failure and strokes.
 After dementia Dx, presence
of AF = higher mortality
(HR=1.38-1.45)
Bunch et al., Heart Rhythm, 2010, 7: 433.
Stroke Risk Reduction
Oral Anticoagulation
 Aspirin.
 Clopidogrel.
 Coumadin.
 Novel Oral Anticoagulants.
 Dabigatran (Pradaxa).
 Rivaroxaban (Xarelto).
 Apixaban (Eliquis).
Procedure/Device Therapy
for Stroke Risk Reduction.
 Surgical LAA amputation.
 Watchman LAA occlude.
 Amplatzer Cardiac Plug.
 Lariat LAA amputation.
Lariat LAA Ligation
LAA Occlusion: Amplatzer
Cardiac Plug
Jain AK, Gallagher S. Percutaneous occlusion
of the left atrial appendage in non-valvular
atrial fibrillation for the prevention of
thromboembolism: NICE guidance. Heart
2011; 97:762.
LAA Occlusion:
Watchman
Jain AK, Gallagher S. Technology and guidelines Percutaneous occlusion
of the left atrial appendage in non-valvular atrial fibrillation for the
prevention of thromboembolism: NICE guidance. Heart 2011; 97:762.
LAA
Occlusion/Amputation.
 Surgical LAA Amputation (Garcia-Fernandez et al., Role of left atrial
appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a
transesophageal echocardiographic study, JACC, 2003, 42: 1253)
 205 patient’s studied retrospectively after mitral valve
replacement + LAA amputation.
 Stroke after 6 years was 3% (vs. 17% for those without LAA
amputation.
 For the most part, standard of care at time of mitral valve
surgery in patient with h/o atrial fibrillation.
 Limited data on stand-alone surgery.
LAA
Occlusion/Amputation.
 Watchman: Protect AF trial
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Non-inferiority, 700 patients randomized 2:1.
CHADS score of 1 or greater.
Primary efficacy and primary safety endpoints.
Concerns about safety. Not yet FDA approved.
 Amplatzer Cardiac Plug
 Lariat LAA amputation: some safety data, limited
efficacy data.
Rate and Rhythm Control
What should be driver for deciding
between rhythm control and rate
control strategy?
1.
2.
3.
4.
Desire to avoid anticoagulation.
Alter long-term prognosis of atrial fibrillation.
Control of symptoms related to atrial fibrillation.
All of the above.
What should be main driver for
deciding between rhythm control and
rate control strategy?
1.
2.
3.
4.
Desire to avoid anticoagulation.
Alter long-term prognosis of atrial fibrillation.
Control of symptoms related to atrial fibrillation.
All of the above.
AFFIRM:
 Randomized, prospective
 4060 patients.
 Rate control (≤80, ≤110 bpm)
 Rhythm control
 Age: 69.7±9.9
 1° endpoint: overall mortality
 Mean f/u 3.5 years
 Rhythm control associated with
more ADRxs, hospitalizations.
Other Rate vs. Rhythm
Trials
 RACE (Hagens et al., JACC, 2004, 43: 241)
 522 patients, 68±9, no difference in composite 1° endpoint.
 PIAF (Hohnloser et al, Lancet, 2000, 356: 1789)
 252 patients, 61±10, no difference in symptoms.
 STAF (Carlsson et al., JACC, 2003, 41: 1690)
 200 patients, 66±8, no difference in composite 1° endpoint.
 HOT CAFÉ (Opolski et al., Chest, 2004, 126: 476)
 205 patients, 61±11, no difference in composite 1° endpoint.
AF and CHF:
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1376 pts (682 vs. 694)
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EF ≤35%
CHF symptoms
h/o atrial fibrillation
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67±1 years old (34 pts <65 y/o)
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1° outcome: time to CV death.
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2° outcomes similar
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All cause death
Stroke
Worsening CHF
Exceptions to Rate vs.
Rhythm Studies?
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Symptoms, Symptoms, Symptoms
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Atrial fibrillation contributing/in-setting of other process
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Patient preference.
Patient expectation.
CHF especially tachycardia-mediated cardimyopathy.
COPD, pneumonia.
Younger age?
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Average age of previous studies was 61-70.
What is appropriate strategy in younger (<50-60) patients?
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Patients with difficult to control heart rates.
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Future studies to determine any additional benefits of ablation.
Other Driver for
Determination of Strategy?
 Vignette #1
 54 y/o male with a-fib diagnosed after presentation for
mild palpitations.
 Initially felt no other new symptoms.
 Now is pre-occupied with a-fib, can’t stop thinking about
it.
 Vignette #2
 74 y/o male with new a-fib.
 DOE, palpitations, exertional intolerance.
Patient Choice
Quick clinical case
 62 y/o male with atrial fibrillation and no Sx.
 CHADSVASC of 0.
 Recent cardioversion failure x3.
 1st w/o AAD.
 2nd on 50 mg bid flecainide.
 3rd on 100 mg bid flecainide.
What is next most appropriate management strategy?
1. Accepting a-fib, rate control strategy.
2. EP study and ablation for PVI.
3. Repeat trial of cardioversion on amiodarone.
4. Repeat trial of cardioversion on non-amio AAD.
Rate Control
Rate Control
 Beta-blockers:
 Metoprolol generally preferred.
 Don’t like atenolol in older patients with CRI
 Carvedilol preferred in LV dysfunction.
 Calcium channel blockers (diltiazem, verapamil):
 Should not be used with LV dysfunction.
 Less of an issue with sinus rate slowing.
 Digoxin: I do not generally use.
HR Target?
 Lenient vs. Strict Rate Control.
 614 patients
 Lenient: resting HR <110 bpm.
 Strict: resting HR <80 bpm, moderate exercise: <110
bpm.
 Primary outcome: composite of CV deaths, CHF
hospitalization, stroke or SE, bleeding and life
threatening arrhythmias.
 2-3 year follow-up.
Lenient vs. Strict Rate
Control
 P<0.001 for pre-specified
non-inferiority margin.
 More patient’s to target in
lenient group.
 97.7% vs. 67%
 Fewer total visits
 75 vs. 684.
 Similar frequency of Sx
and Aes
 Exceptions?
Rhythm Control
Rhythm Control
 Cardioversion.
 Quick, easy.
 Infrequent cardioversion acceptable as sole rhythm control.
 Medications (Anti-arrhythmics).
 Numerous, can feel like “spinning” your wheels.
 Class IIa recommendation: “Infrequent, well-tolerated
recurrence of AF is reasonable as a successful outcome of
antiarrhythmic drug therapy.”
 Ablation.
2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation
(Updating the 2006 Guideline) : A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
Ablation Strategies for
Atrial Fibrillation
Rationale For A-fib
Ablation: PVI
What is success rate of ablation for
atrial fibrillation (PVI)?
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2.
3.
4.
50%
65%
75%
Who knows/Need more information.
What is success rate of ablation for
atrial fibrillation (PVI)?
1.
2.
3.
4.
50%
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most AADs
65%
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amiodarone
75%
Who knows/Need more information.
Ablation vs. AADs
 Meta-analysis
 6 studies.
 Prospective studies.
 Mainly
paroxysmal/persiste
nt.
 693 total patients.
 65% RRR of a-fib
with ablation
Nair et al., JCE, 2009, 20: 138.
Ablation Success/Risks
 Questionnaire study (Cappato et al., Circ Arrhyth Elect,
2010, 3(1): 32.
 Worldwide survey (521 centers)
 Results: 20825 ablations (16309 patients, 2003-2006)
 Mean f/u: 18 months (3-24 months)
 10488 asymptomatic w/o AADs
 2047 asymptomatic w/ AADs
 Conclusions:
 Effective in 80% of patients after 1.3 procedures/pt
 Effective w/o AAD in 70%
 Major complications: 4.5%
Atrial Fibrillation Ablation
 In general, ablation has better success rates.
 Ongoing trials.
 Technology/strategies continue to evolve.
 Appropriate candidates for ablation:
 Significant symptoms to warrant rhythm control.
 Failure/intolerance of anti-arrhythmics.
 Desire to not take anti-arrhythmics.
Guidelines: 2011 ACCF/AHA/HRS
Focused Update on the Management of Afib (Update of 2006 Guidelines)
 Class I: Catheter ablation performed in experienced
centers (>50/year) is useful in maintaining sinus
rhythm in selected patient with significantly
symptomatic, paroxysmal AF who have failed
treatment with an AAD and have normal-mildly
dilated LA, normal-mildly reduced LV function and
no severe pulmonary disease.
Guidelines: 2011 ACCF/AHA/HRS
Focused Update on the Management of Afib (Update of 2006 Guidelines)
 Class IIa: Catheter ablation is resonable to treat
symptomatic persistent AF.
 Class Iib: Catheter ablation may be reasonable to
treat symptomatic paroxysmal AF in patients with
significant left atrial dilation or with significant LV
dysfunction.
Future of Rhythm Control
 Do results of Affirm and other rate vs. rhythm control
studies apply to atrial fibrillation ablation?
 On-treatment analysis of Affirm.
 Independent studies looking at benefits of a-fib ablation.
 Ongoing and future trials of a-fib ablation: CABANA
Exceptions to Trials
 On-treatment analysis of
AFFIRM
 SR and warfarin use
associated with lower risk of
death.
 AADs use associated with
increased mortality
 AADs no longer associated
with mortality after
adjustment for SR
Corley et al., Circulation, 2004, 109: 1509-1513.
Effects of A-fib Ablation on
Risk of Stroke and Death
 International multicentre registry
 7 countries in UK and Australia.
 Consecutive patients undergoing catheter ablation of
AF.
 1273 pts, 58±11 years
 Long-term outcomes compared to:
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Cohort with AF treated medically in Euro Heart Survey.
Hypothetical cohort without AF but age and gender.
 Analysis after 1st procedure regardless of success,
intention-to-treat basis.
Effects of A-fib Ablation on
Risk of Stroke and Death
 Success rates:
 Paroxysmal: 85% (76% off
AAD).
 Persistent: 72% (60% off
AAD).
 Lower rates of stroke and
death in cohort compared to
medical treatment.
 Rates of events no different
compared to general
population.
Hunter et al., Heart, 2012; 98: 48.
Practical Management
Triage:
st
1
presentation.
 Admit/ER evaluation vs. outpatient management.
 Unstable patient?—think of other cause!
 PE
 CHF
 ACS, etc.
 Heart rate unacceptably high?
 What is cut-off for “too high”?
 Generally make decision based on symptoms.
Outpatient Management
 Decision on OAC.
 Long-term management: CHADSVASC score vs. Risks of OAC.
 If above risk is low, plan for rhythm control in future?
 Routine tests:
 Echo, TSH, CBC, chemistry panel.
 Need evaluation for OSA.
 Are other symptoms present requiring further work-up.
 Rate vs. Rhythm control.
 I always offer a trial of rhythm control.
 Referral?
Thank You.