OUTLINE Case studies 1) AF on pacemaker 2) AFL on dofetilide - - PDF document

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The more we look the more we see The more we see the less the we know… David Singh MD Cardiac Electrophysiology Queens Medical Center

OUTLINE

 Case studies  1) AF on pacemaker  2) AFL on dofetilide patient  3) Post ablation patient  BACKGROUND AF  Description change in monitoring

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Mobile telemetry

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Patches

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ILR 

AF burden and stroke‐ review trials

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Are symptomatic AF and asymptomatic AF different

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ASSERT

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TRENDS 

Montoring AF post ablation/aa drug therapy

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Case illustrating post ablation 

Cryptogenic stroke

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Case 1

 78 year old female s/p AFIB ablation X 2 at UCSF  Despite ablation continued to have frequent AF and

feels terrible when she is in it.

 Started on Dofetilide and cardioverted  Since then has been feeling great subjectively no AF  Has a history of HTN  CHADS Vasc of 3  Since she feels she has no Afib she would like to get off

• f OAC

Next Steps?

 1) Tough luck: you are stuck with OAC  2) Sounds great! Lets stop your OAC  3) Perform monitoring to determine AF burden and

make decision based on results.

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Case 2

 84 year old with history of AFL s/p Ablation  EF 25%  Was on coumadin but stopped because of mild GI

bleed

 CHADS VASC of 4  SSS s/p SCPM

Interrogation in office 10/2014

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CASE 3

 61 year old man with long standing peristent AF  s/p ablation for AF  Having symptoms here and there post ablation  Office ECG’s all NSR

ALIVECOR Monitor

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Implantable Cardiac Devices and Atrial Arrhythmias

 Over 400,000 pacemakers and implantable

cardioverter–defibrillators (ICDs) implanted each year in North America

 Asymptomatic Atrial Arrhythmias are frequently seen

in patients undergoing device interrogation

 Do subclinical episodes of AF increase the risk of

stroke?

Atrial Fibrillation Truths

 Atrial fibrillation (AF) is the most commonly treated

tachyarrhythmia worldwide. Population projections indicate that the prevalence of AF could exceed 5 million by 2050 in the United States alone.

 AF raises the risk of stroke even in low risk patients  Oral Anticogulation Reduces the risk of stroke in AF

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ASSERT TRIAL ASSERT TRIAL

 2580 patients with newly implanted ICD or PM  No history of AF  Assessed for the presence of subclinical atrial

arrhythmia at 3 months and followed for 2.5 years

 10% found to have subclinical atrial arrhythmia at 3

months, 34.7% at follow up (mean 2.5 years)

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Does AF Burden Correlate with Risk?

Circ Arrhythmia Electrophysiol. 2009;2:474‐480

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TRENDS

 2486 patients with 1 stroke risk factor (heart

failure, hypertension, age 65 years, diabetes, or prior TE) with pacemakers or defibrillators capable

• f monitoring AF

 AF burden was defined as the longest total AT/AF

duration on any given day during the prior 30‐day period

 Annualized TE rates were determined according to

AT/AF burden subsets:

 zero, low <5.5 hours, high >5.5 hours

TRENDS

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TRENDS

Temporal Relationship between CVA and AF

 In TRENDS 40 patients had TE (both AF and non AF

patients)

 50% of patients who experienced TE had AT/AF prior

to the event.

 Of the 20 patients with AT/AF prior to TE, 9 (45%) did

not have any AT/AF within 30 days.

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Daoud, Heart Rhythm, 2011;8:1416 –1423

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TRENDS

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