Disclosures Atrial Flutter: Optimal Management Major Strategies - - PDF document

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Atrial Flutter: Optimal Management Strategies in 2016

17 December 2016 33rd Annual Advances in Heart Disease Park Central Hotel, San Francisco Zian H. Tseng, M.D., M.A.S. Murray Davis Endowed Professor Associate Professor of Medicine in Residence Cardiac Electrophysiology Section University of California, San Francisco

Disclosures

◆ Major

◆ Research grant: R01 HL102090 (NIH / NHLBI) ◆ Research grant: R01 HL126555 (NIH / NHLBI) ◆ Research grant: DP14-1403 (CDC) ◆ Research grant: R24 A1067039 (NIH) ■ Classification & ECG features ■ Etiology, risk factors, epidemiology ■ Treatment

◆ Rate control ◆ Reversion to NSR ◆ Maintenance of NSR ◆ Prevention of thromboembolism

Outline

■ Mechanism

◆ Macro-reentrant atrial circuit around a non-

conducting obstacle, anatomical or electrophysiologic (scar)

■

Typical

◆ circuit traverses the cavo-tricuspid isthmus

(CTI: between IVC and TV annulus)

◆ CCW >> CW (“reverse”)

■ Atypical

◆ CTI not involved ◆ CHD, atriotomy scar, ASD, incomplete RFCA

lines after PVI

Classification

Lee G et al. Lancet 2012; 380, 9852

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Sawtooth atrial pattern Atrial rate ~300 bpm, cycle length perfectly regular RR interval can help

ECG Features

■ 2:1 AV conduction most common

◆ Even A:V rate ratios (2:1 or 4:1) > odd

ratios (3:1 or 5:1)

■ 1:1 in high catechol states ■ 1:1 on class IC AAD without AVN blocker

ECG Features

■ 1:1 with accessory pathway (WPW)

ECG Features

P wave rate ~300 bpm

CCW

■

• P waves II,

III, aVF

■

+ P waves V1

CW

■

+ P waves II, III, aVF

■

• P waves V1

Typical Atrial Flutter

Cosio F et al. Rev Esp Cardiol. 2006;59:816-31

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Typical CCW Atrial Flutter

Bun SS et al. Eur H J (2015) 36, 2356–2363

Atypical Atrial Flutter

Lee G et al. Lancet 2012; 380, 9852

ECG Features ECG Features

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■ Incidence

◆ 181 AFL over 4 y in population based

study of 58,000 adults

✦5 per 100,000 p-y < age 50 ✦587 per 100,000 p-y > age 80

◆ 2.5 x higher in men ◆ ~200,000 AFL in U.S. per year

Epidemiology

Grenada J, et al. JACC 2000;36(7):2242 Garson A, et al. JACC 1985;6(4):871

■ As with AF, highest with underlying

heart disease, LAE, or RV/LV dysfunction

■ 16% HF ■ 12% COPD ■ 1.7% (3 of 181) Normal heart/”lone” ■ 8% lone AFL in children and young adults

■ Rare after MI ■ Rare in digoxin toxicity

Epidemiology

Grenada J, et al. JACC 2000;36(7):2242 Garson A, et al. JACC 1985;6(4):871

■ Risk factors ◆ After AAD for AF: ~15% in pts on class IC (flecainide

• r propafenone)

◆ Similar to those for AFib

✦ thyrotoxicosis ✦ obesity ✦ OSA ✦ SSS ✦ pericarditis ✦ COPD ✦ PE

◆ After cardiac surgery: typical or atypical ◆ After AFib ablation: Atypical circuits created by

ablation scars, amenable to ablation

Epidemiology

Grenada J, et al. JACC 2000;36(7):2242 Garson A, et al. JACC 1985;6(4):871

■ Ischemia ■ pre/syncope

rate control

■ HF ■ Thromboembolism/CVA ■ Tachycardia induced CM ■ rate + rhythm control

Complications

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■ Ventricular rate control ■ Reversion to NSR ■ Maintenance of NSR ■ Prevention of

thromboembolism/CVA

Treatment Objectives

■ More difficult than for AF

◆ “stuck” at 2:1

■ Non-dihydropyridine Ca2+CB or ßB ■ Digoxin rarely used

◆ Mechanism: ^ vagal tone ◆ HF: dig + ßB

■ IV Amiodarone in acutely ill ■ AVJ ablation rarely indicated

Rate Control

■ RFCA may be considered first line

◆ Exception for AFL w/ reversible triggers:

PNA, hyperthyroid, etc.

◆ ~92-97% success for typical AFL ◆ Often more sx than AF, ^ ßB needed

■ AAD vs. RFCA

◆ 61 pts ≥ 2 episodes of sx AFL within 4 mo

period, mean F/U 21 months

◆ NSR: 80% RFCA vs. 36% AAD, p<0.01 ◆ Rehosp: 22% RFCA vs. 63% AAD, p<0.01 ◆ AF: 29% RFCA vs 53% AAD, p < 0.05 ◆ QOL improvement with RFCA but not AAD

Reversion to NSR

Spector P et al. AJC 2009;104(5):671. Natale A, et al. JACC 2000;35(7):1898

Ablation of Typical Atrial Flutter

Lee G et al. Lancet 2012; 380, 9852

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P wave rate ~300 bpm

CCW

■

• P waves II,

III, aVF

■

+ P waves V1

CW

■

+ P waves II, III, aVF

■

• P waves V1

Typical Atrial Flutter

Cosio F et al. Rev Esp Cardiol. 2006;59:816-31

Atypical Atrial Flutter

Lee G et al. Lancet 2012; 380, 9852

Ablation of Atypical Atrial Flutter

Lee G et al. Lancet 2012; 380, 9852

◆RFCA success is lower, may not be considered firstline ◆Tertiary care center w /high volume experience ◆High recurrence of other atypical AFL and AF

Atypical AFL Masquerading as Typical AFL

Bun SS et al. Eur H J (2015) 36, 2356–2363

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Atypical AFL after PVI

Bun SS et al. Eur H J (2015) 36, 2356–2363

■ If no RFCA, DCCV >> AAD

■ Only IV ibutilide labeled for acute conversion

◆ 60% success, can also potentiate DCCV ◆ Confirm K+ > 4.0, Mg2+ > 2.0 ◆ Continuous monitoring for TdeP 4h (up to 8% risk) ■ If preexcitation (WPW):

◆ IV Ibutilide (III) or procainamide (IA)

■ AOD pacing

◆ PPM in place ◆ Post CTS with epicardial wires in place

■ AC or TEE if >24-48h or unknown

Reversion to NSR

Spector P et al. AJC 2009;104(5):671. Natale A, et al. JACC 2000;35(7):1898 ■ AFL recurrence after CV

◆ 50 pts after CV, no AAD

✦ 47% (6m), 58% (5y)

◆ Lone AFL: Up to 75% recurrence

■ AFib recurrence after AFL RFCA: 7 – 82%

◆ If AFib before: 36% ◆ If no AFib before: 13% ◆ Higher risk if LA > 4.0cm

■ Careful monitoring before stopping AC ■ Consider PVI + AFL RFCA or CV + AAD if Afib

found

■ AAD to suppress initiating PACs

◆ IA, IC, ßB, amiodarone, dofetilide

Maintenance of NSR

Crijns HJ, et al. Heart 1997;77(1):56. Halligan SC, et al. Ann IM 2004;140(4):265 ■ Identical to Afib

◆ Embolic risk similar ◆ 100 pts after CV for chronic AFL (6 mo)

✦ CVA rate: 6% on AC vs. 0% no AC (p=0.02)

◆ Many also have Afib

■ CHA2DS2-VASc

◆ ≥2 pts: AC

• Male (0 pt); Female (1 pt)
• ≤64 yo (0 pt)
• 65 to 74 yo(1 pt)
• ≥75 yo (2 pts)
• CHF (1 pt)
• HTN (1 pt)
• DM (1 pt)
• H/o of CVA, TIA, or thromboembolism (2 pts)
• Vascular disease (h/o MI, PAD, or aortic atherosclerosis) (1 pt)

Prevention of Thromboembolism/CVA

Lanzarotti CJ, et al. JACC 1997;30(6):1506

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■ Warfarin goal INR 2.0 to 3.0 ■ NOACs: only Apixiban enrolled AFL pts ■ All NOACs likely similar (dabigatran [bid],

rivaroxaban [qd], apixiban [bid], edoxaban[qd])

■ For Lone AFL (no triggers, CHA2DS2-VASc 0-1)

◆ 1 mo before CV or RFCA if no TEE ◆ 1 mo after CV or RFCA

■ For CHA2DS2-VASc ≥ 2

◆ AC unless contraindicated ◆ If considering stopping AC after 1 mo, careful close

monitoring for AFib (long-term monitor or Linq)

Prevention of Thromboembolism/CVA

■ AFL is a macroreentrant circuit

◆ Identical FL waves on ECG ◆ Typical CCW pattern most common

◆ - P waves II, III, aVF ◆ + P waves V1 ■ AFL Incidence and RFs parallel Afib ◆ Up to 100X more common in > 80 yo ◆ More common in men ◆ CHF, LAE, COPD, thyrotoxicosis, post CTS ◆ post PVI for AFib

Take Home Points

■ Rate control

◆ Non-dihydropyridine Ca2+CB or ßB ◆ IV Amiodarone in acutely ill

■ Reversion to NSR ◆ RFCA may be considered first line for typical AFL ◆ RFCA is a good option for atypical AFL at high

vol centers

◆ CV if acutely ill or not RFCA candidate ◆ Consider IV ibutilide if anesthesia is a concern ◆ AC or TEE if >24-48h or unknown

Take Home Points

■ Maintenance of NSR ◆ AFL recurrence after CV high ◆ Careful monitoring before stopping AC ◆ Search for evidence of prior AFib ◆ Consider PVI + AFL RFCA or CV + AAD if Afib found ◆ AAD: IA, IC, ßB, amiodarone, dofetilide ■ Prevention of TE/CVA ◆ Identical to Afib ◆ CHA2DS2-VASc: ≥2 pts use AC ◆ Warfarin goal INR 2.0 to 3.0 or NOACs if renal

function allows

◆ If considering stopping AC, careful close

monitoring for Afib

Take Home Points

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