Fibs and Flutters: The Heart of the Matter Anita Ralstin, CNP By - - PDF document

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Fibs and Flutters: The Heart of the Matter Anita Ralstin, CNP By the Numbers

 Atrial Fibrillation Hospital Discharges /quarter for

2012 -- 116,500

 Average Length of Stay – 4 days  Projected that 20% of those over 80 years have

atrial fibrillation

 Prevalence: 2,000,000 US

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What is Atrial Fibrillation?

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What is Atrial Fibrillation?

 An irregular heart beat generated when the top

chambers of the heart are beating very rapidly.

 Atrial fibrillation compromises several aspects of heart

function.

 Rate  Regularity of the heart rhythm  Loss of loading the ventricle with blood  Loss of the forceful atrial contraction slows blood flow

in the top chambers of the heart.

Are there different kinds?

 Paroxysmal (self-terminating)- sustained > 30

seconds

 Persistent (>7d)- requires shock to terminate  Permanent- unable to convert except with surgery

• r ablation

 First detected episode vs. recurrent  Secondary AF- pneumonia, heart surgery etc.  Lone AF- no other heart disease

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What causes Atrial Fibrillation?

Triggers for Atrial fibrillation

Triggers

 Pulmonary veins  Account for ~70% of atrial fibrillation in men  60% in women  Ganglionated plexi 20%  Other thoracic veins 10% in both sexes  Nonvenous locations  LA Posterior wall, CS OS, Crista Terminalis  Triggers elimination is curative.

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Case 1

 58 year old woman  History of symptomatic bradycardia and PPM  Device check shows 2 episodes of atrial fibrillation

with ventricular rate to 188, longest duration; 2 hours 14 minutes

 Patient is asymptomatic  History includes hypertension  Current medication: Micardis  Echo and stress of 1/2013 WNL

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Goals of Therapy

 Prevent Stroke- appropriate anticoagulation  Prevent CHF- rate control, HTN control  Acute symptomatic CHF related to rate  Chronic diastolic CHF in older patients  Control symptoms

What symptoms come from Atrial Fibrillation?

 Palpitations, chest pain  Fatigue  Shortness of breath with exertion  Leg swelling  Difficulty concentrating  Difficulty sleeping  Lightheadedness with change of position  Fainting

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Case 1

 Type of atrial fibrillation?  New onset, paroxysmal  Concerns about rate or rhythm?  HR of 188  Yet to determine burden  What is her stroke risk?

Replacing the CHADS2 score

 CHADS2 score- not everyone needs warfarin  2 points for prior stroke  1 point for congestive heart failure, high blood pressure, age

>75 and diabetes.

2006 ACC/AHA Guidelines for atrial fibrillation management

• In most series 25-35% of the

patients are in the indeterminate range

• Are low risk patients low

risk?

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CHA2DS2 Vasc Score

 Congestive Heart Failure  Hypertension  Age>75 (2 points)  DMII  Prior Stroke (2 points)  Age 65-74  Vascular disease (PVDz, aortic atheroma)  Female Sex

CHADS vs. CHA2DS2 VASc

 121,281 patients with nonvalvular Afib  The critical area is the in the low and intermediate risk patients Oleson, JB et al, BMJ online first December 2010 :1-9.

* *

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CHA2DS2 VASc is Superior

 Low risk CHADS2= 39% intermediate risk, 21%

high risk (only 40% were “low risk) by CHA2DS2 VASc

 Intermedite CHADS2=93% at high risk  CHA2DS2 VASc not only predicted TE better but also

mortality better

 C statistics for the low, intermediate and high for

CHA2DS2 VASc were much better.

 CHA2DS2 VASc =0 no anticoagulation Oleson, JB et al, BMJ online first December 2010 :1-9.

Case 1

 What is her need for anticoagulation  CHADS2 score = 1 (HTN)  CHADS2Vasc = 2 (HTN and Gender)  Also consider burden  3 hours or more when identified on device

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Case 1 Plan

 Patient education  What is atrial fibrillation  Monitor for symptoms  Address anxiety  Rate Management  Beta blocker, calcium channel blocker or digoxin  Consider ejection fraction and side effects  Anticoagulation:  ASA 81 mg – 162 mg (chewable)

Will it get worse?

 Lone Atrial Fibrillation- rare  No evidence that it will progress  Paroxysmal atrial fibrillation  15%/year progress to persistent atrial fibrillation  More heart disease means more likely to progress  Progression generally means more symptoms  Older, sicker patients move towards more atrial

fibrillation.

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Case 2

 60 year old male  New onset atrial fibrillation with shoulder surgery  Onset documented with hospitalization.  Symptomatic with rapid ventricular rate (RVR): hypotensive  PMH  Hypertension  Gout  Barrets Esophagus  Smoker  Obese

Atrial Scarring

 Injury to the heart muscle  Age  High blood pressure  Structural problems in the heart  Heart attacks, valve problems, congestive heart failure  Sleep apnea  Obesity  Alcohol  Repeated exercise  All of these lead to fibrosis

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Case 2 Diagnostic

 Echocardiogram: Normal EF, Moderate left atrial

enlargement

 Lab work: no significant abnormals

Case 2 Hospital Treatment

 EP consult  Rate control  Diltiazem drip  Hypotension  IV metoprolol  Short acting  Digoxin load  Consider renal function

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Case 2 Contd

 Rhythm Control: Hospital  If unstable and known duration of <48 hours  Synchronized cardioversion  If unstable and unknown duration  TEE and cardioversion  Antiarrhythmic  Amiodarone drip to PO

Case 2 Still in the Hospital

 Anticoagulation  CHADS Vas score = 1 (HTN)  Heparin to warfarin initiated  Cardioversion results in atrial stunning and increases risk of

thrombus early post CV

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Case 2 Office Visit

 Presented complaining of fatigue, irregular HR,

generally not feeling well

 ECG shows recurrent atrial fibrillation, rate 95 on

diltiazem

 Anticoagulation has been stable  INR goal for atrial fibrillation 2.0-3.0

Why does it keep going?

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Case 2

 Type of atrial fibrillation: Recurrent, persistent  Treatment goals:  Rate control (goal 80-110)  Symptom goal  Rhythm goal

Adding Antiarrhythmic Therapy

 AAD for Rhythm Control  Amiodarone  SE makes less desirable for younger pts: monitor thyroid,

liver and pulmonary

 Dronedarone  Avoid with HF  Flecainide  Not with structural heart disease  Propafenone  Renal dosing; hospital start  Sotalol  Hospital start

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Case 2

 Normal structural heart  Flecainide 50 mg BID  Continue anticoagulation  Consider atrial fibrosis  Add spironolactone  Evaluate for sleep apnea

Sleep Apnea

 Sleep Heart Health Study  2800 patients  Took PSGs from the patients with afib and performed

case control analysis

 Matched sleep stages, no PVCs and no pauses  Used the entire group to estimate total event rates  62 total arrhythmic periods were found  Afib and NSVT were the most common Monahan, K, et al. JACC 2009

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Mankopf,C, HRS 2010

Case 2 Next Visit

 Return visit  Ongoing similar symptoms of fatigue and palpitations  ECG shows persistent atrial fibrillation  Options  Repeat cardioversion  Change AAD  Consider pulmonary vein ablation

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Atrial Fibrillation Ablation

 Atrial fibrillation ablation right now  CT scan of the chest beforehand  4 hours under general anesthesia  1 night in the hospital  Coumadin 1 month before and 3 months afterwards  80-85% cure rate

 requires >1 procedure 10% of the time.

 Complication rate 10% (mostly minor)

 Bleeding/perforation 3% usually managed with a drain  Stroke 0.2%  Esophageal injury 0.1%  Death 0.1%

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Case 3

 88 year old female referred by PCP for atrial

fibrillation found on ECG, HR 55 BPM

 History  Mild dementia; diabetes, hypertension, recent fall and

hip fracture

 Symptoms  Fatigue, increased confusion, edema and shortness of

breath

Case 3 Diagnostic

 Echocardiogram shows LV EF 25-30% with bi-atrial

enlargement

 Lab: renal insufficiency and anemia

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Case 3 Treatment Goals

 Rate control  Has underlying conduction issues if rate in the 50s not

• n any rate control meds

 Rhythm control  Is this reasonable?  Could she be cardioverted?  Anticoagulation

Assessing Bleeding Risk

 HAS-BLED" 1 point for each  Hypertension  Abnormal Liver/Renal Function  Stroke History  Bleeding Predisposition  Labile INRs  "Elderly" (Age >e; 65) (fall risk)  Drugs/Alcohol Usage

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Case 3 Treatment Plan

 Rate control  PPM +/- AV node ablation  Rhythm management  Not appropriate  Anticoagulation  ASA 81 mg daily

Vitamin D and Afib

 30-50% of the Americans are Vitamin D deficient  Retrospective study of patients.  Vitamin D deficient patients slightly less likely to have

atrial fibrillation (OR=0.83)

 More likely to have HTN, DMII (OR=1.4, 2.31).  CAD/CM more likely (OR= 1.16, 1.4) Howard, PA et al, AJC, 109:359-363, 2012

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Atrial Flutter Atrial Flutter

 Regular arrhythmia  Flutter waves visible (CL 200-280ms)  V1- isoelectric component  III and aVF- downward continous  Difficult to rate control  Usually sustained until intervention (stable arrhythmia)  Pulmonary disease (DDimer)  Sleep apnea

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Atrial Flutter Ablation

 Even in the elderly  95% success rate  1/500 minor complication  Fewer medications, fewer readmissions, less CHF  VERY IMPORTANT  Atrial fibrillation occurs in 40-50% of these patients

• ver 5 years.

 Slow to stop warfarin even though AFL cured

Atrial Flutter

 Typical  Flutter waves visible (CL 200-280ms)  V1- isoelectric component  III and aVF- downward continuous  Atypical  Flutter waves visible, but not typical morphology  Usually have had prior heart surgery or atrial ablation

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Rely; Rocket AF; Aristotle

 New anticoagulants show equivalency or superiority

compared head to head with warfarin for nonvalvular Afib.

 Dabigatran- Rely  Rivaroxaban- Rocket AF  Apixaban- Aristotle

Trial Data

Drug/Trial Efficacy: Stroke/ Thromboembolism Hemorrhagic Stroke Major Bleeding Dabigatran in RE-LY 34% reduction 74% reduction Similar Rivaroxaban in ROCKET Noninferior to warfarin 40% reduction Similar Apixaban in ARISOTLE 20% reduction 50% reduction 30% reduction Major Results of Phase 3 Trials of New Anticoagulants vs Warfarin in AF

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Dabigatran

 Dabigatran- oral prodrug converted to active agent

by serum esterase

 Competitively blocks thrombin  12-17 hour half life  Cleared by the kidneys 80%  FDA APPROVED EARLY DEC 2010.

Conolly,SJ, NEJM Sept 2009

Dabigatran Bottom line

 Useful for plain old Afib  40% less strokes  No INR testing  Fast onset, fast offset (hold for 2 days)  10% have GI distress  Difficult to reverse  Expensive ($40 to $240/month)  Not safe for continuation through procedures  Interacts with multiple medications  ? Safe in patient with CAD

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Rivaroxaban

 Oral once daily direct factor Xa inhibitor  Lovenox and fractionated heparins  Peak effect is 4 hours after a dose  Half life is 8-12 hours but Xa is inhibited for 24

hours allowing 1x daily dosing

 CYP3A4 dependent metabolism, 2/3 hepatically

eliminated

 Accumulates CrCl<50.

Rivaroxaban Bottom Line

 Proven safe in high CHADS2 patients  Once daily  Proven safe in ACS and PE  Fast onset and offset  Cost….

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Apixaban

 • The recommended dose is 5 mg orally twice daily.  • In patients with at least 2 of the following

characteristics: age ≥80 years, bodyweight ≤60 kg, or serum creatinine ≥1.5 mg/dL, the recommended dose is 2.5 mgorally twice daily.

 a factor Xa inhibitor anticoagulant indicated to

reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.

Apixaban

 New to the market  Same indications  Fewer SE  BID dosing  Renal dosing  Cost

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Nurse Practitioner