Practical Approaches to Atrial Fibrillation Management Answ ers to - - PowerPoint PPT Presentation

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Practical Approaches to Atrial Fibrillation Management Answ ers to - - PowerPoint PPT Presentation

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Practical Approaches to Atrial Fibrillation Management Answ ers to Your Everyday Questions H. Mark Guo, MD, FACC, FHRS Clinical Cardiac Electrophysiology Oregon Heart & Vascular Institute hguo@ peacehealth.org Disclosure SYSTEMS OF

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SLIDE 1

Practical Approaches to Atrial Fibrillation Management

Answ ers to Your Everyday Questions

  • H. Mark Guo, MD, FACC, FHRS

Clinical Cardiac Electrophysiology Oregon Heart & Vascular Institute hguo@ peacehealth.org

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SLIDE 2

Disclosure

SYSTEMS OF CARE SYMPOSIUM 2015

Care of Your Patient in the Era of Population Health

Hongsheng Mark Guo, MD, FACC, FHRS

  • I use free pens from all industrials.
  • I have no other financial relationships

to disclose.

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SLIDE 3

Thursday 8 am: 63 yo man calls from MSP

  • In “AF” at least since Tuesday morning
  • Had breakfast in Indianapolis at 5:00am
  • Flight changed to 7:00pm to continue trip
  • Insists on not delaying trip any later
  • Previous episode in 5/2004 (metoprolol and

propafenone)

  • Cardioversion scheduled 4:00pm
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SLIDE 4

ECG @ 9:40 am 4/26/07

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SLIDE 5

What would you do?

A. Cardioverte and catch flight B. Cancel cardioversion, titrate BB, start coumadine, cardioverte after trip C. Cardioverte, start lovenox and coumadine, f/u w ith ACC D. Cancel cardioversion, titrate BB, start coumadine, ablation after 3-4 w eeks AC E. Start NOAC, TEE, cardioverte if no clot

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SLIDE 6

What is AF?

  • AF is the most common sustained

arrhythmia.

  • Prevalence: 0.4% to 1% in general

population, increasing w ith age to 12% for those > 75 yrs.

  • Stroke rate: < 1% to > 15% annually,

depending on comorbid risk factors.

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SLIDE 7

Atrial Fibrillation Is Common

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SLIDE 8

Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.

U.S. population Population with atrial fibrillation Age, yr

<5 5- 9 10- 14 15- 19 20- 24 25- 29 30- 34 35- 39 40- 44 45- 49 50- 54 55- 59 60- 64 65- 69 70- 74 75- 79 80- 84 85- 89 90- 94 >95

U.S. population x 1000 Population with AF x 1000

30,000 20,000 10,000 500 400 300 200 100

Atrial Fibrillation Demographics by Age

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SLIDE 9

What is the Pathophysiology of AF?

  • AF may be triggered by a focal source of

rapid atrial electrical depolarization, often in the pulmonary veins.

  • It is sustained by the presence of multiple

reentrant w avelets or spiral w ave re- entrant circuits (rotors).

Theories (Too Simple to be perfect) Wishes and dreams. Clueless!

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SLIDE 10

What causes my AF?

  • Acute and temporary causes (triggers)

– alcohol intake (holiday heart) – surgery (particularly cardiac surgery) – MI, pericarditis, myocarditis, CHF – pulmonary embolism – hyperthyroidism.

  • Concurrent treatment of the underlying

disorder and management of AF

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SLIDE 11

Other Causes of AF

  • Triggered by other arrhythmias

– atrial tachycardia – atrial flutter – Wolff-Parkinson-White (WPW) syndrome – AV nodal reentrant tachycardia.

  • Associated w ith chronic disorders

– sleep apnea – hypertension – obesity

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SLIDE 12

How to establish an accurate diagnosis of AF?

  • Symptoms maybe absent Not Reliable
  • “Irregularly irregular rhythm”
  • ECG

– 12-lead – Ambulatory: Holter, Event monitor, ILR – Device interrogation

  • Should be distinguished from

– atrial flutter, – multifocal atrial tachycardia – reentrant SVTs, such as AV nodal reentry; – sinus rhythm (SR) w ith multiple premature atrial complexes.

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SLIDE 13

Are all AFs the same?

  • Paroxysmal

– terminates spontaneously w ithin 7 days of onset

  • Persistent

– sustained > 7 days – longstanding persistent: continuous AF > 12

months duration.

  • Permanent
  • Lone AF
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SLIDE 14

Are all AFs treated in the same w ay?

  • Hemodynamically unstable:

– Immediate cardioversion, sedate if possible – Refractory, IV amiodarone, ibutilide, or procainamide.

  • Hemodynamically stable:

– Cardioversion: new ly diagnosed, onset w ithin 48 hours – Rate control, anticoagulation if indicated – Cardioversion after 3-4 w eeks anticoagulation or no clot on TEE and therapeutic anticoagulation initiated.

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SLIDE 15

Case

  • 72 yo w oman, POD #1 (Ovarian mass removal), ECG

show s AF HR 100-120 bpm, BP 158/66, R 18

  • PMH: HTN, and CAD w ith LCx stented 5 yr ago
  • What w ould be your most appropriate next step:
  • A. Cardioversion
  • B. Aspirin
  • C. Warfarin/NOAC
  • D. Metoprolol
  • E. TEE
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SLIDE 16

CASE

  • TEE is performed. Most likely

result you predicted is:

  • A. LAA thrombus
  • B. Spontaneous echo contrast (smoke) in LA
  • C. Clear LAA
  • D. Annual stroke risk is 1-2%
  • E. Annual stroke risk is 3-5%
  • F. Annual stroke risk is 5-9%
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SLIDE 17

Risk factor score

C

Conge stive he ar t failur e / L V dysfunc tion

1

H

Hype r te nsion

1

A2

Age ≥75y

2

D

Diabe te s me llitus

1

S2

Str

  • ke / T

IA/ T E

2

V

Vasc ular dise ase (pr ior myoc ar dial infar c tion, pe r iphe r al ar te r y dise ase , or aor tic plaque )

1

A

Age 65-74y

1

Sc

Se x c ate gor y (ie fe male ge nde r )

1

Maximum Sc or e

9

L ip GY, e t a l., Che st 137, 263-272, 2010

maximum sc o r e is 9 sinc e age may c o ntr ubute 0, 1, o r 2 po ints

CHA2DS2-VASc

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SLIDE 18

CHA2DS2-VASc – overall event rates

%/year

CHA2DS2-VASc

0-1 634 2 3408 3 5365 4 4378 5 2566 6 1185 7 451 8-9 125

No of patients

Stroke and systemic embolism

1 2 3 4 5 6

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SLIDE 19

Marine JE. JAMA. 2007; 298(23): 2368-2778

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SLIDE 20

Cryoballoon

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Atrial Fibrillation Ablation:

Success & Repeat Procedures

  • 50 – 70% success w ith a single procedure
  • Up to 50% w ill require a second procedure to

achieve success

  • 50% w ill have early recurrence w ithin the

first couple days to w eeks

– 50% of these w ill resolve w ithin few w eeks and still have success

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SLIDE 22

Atrial Fibrillation Ablation: Long Term Outcome

Free of antiarrhythmic drugs and free of arrhythmia symptoms at 6 months

  • Paroxysmal

– 70 to 90%

  • Persistent (lasts > 7 days, up to 1 year)

– 60 to 80%

  • Long standing persistent (> 1 year)

– 50 to 70%

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SLIDE 23

Atrial Fibrillation Ablation: What are the risks?

  • Major: (overall risk < 1%)

– Stroke (0.2%) – Heart attack (< 0.02%) – Atrial-esophageal fistula (rare – 0.02%) – Death (0.1%)

  • Intermediate:

– Pulmonary vein narrow ing or stenosis (0.3%) – Bleeding around the heart or tamponade (1.0%) – Diaphragm paralysis (0.2%) – Need for a pacemaker (rare - < 0.02%)

  • Minor:

– Groin site bleeding or hematoma (1 - 3%) – Infection (0.01%)

* Second Worldw ide Survey on the Efficacy and Safety of Catheter Ablation for Atrial Fibrillation

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SLIDE 24

Atrioesophageal Fistula

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SLIDE 25

Catheter Ablation: How Is A Cure Delivered?

  • Better understanding of

mechanism

  • Fixed circuits or foci
  • Target: substrate
  • Mechanism?

– Microreentry – Multiple w avefronts – No fixed circuit – Triggers

  • Target(s):

– Triggers? – Drivers? – Substrate? – Autonomic nerves?

Conventional AF Ablation

Atrial flutter AVNRT WPW Focal atrial tachycardia VT

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SLIDE 26

“What Is EP?”

  • Precision
  • Perfection

Cure Satisfaction

  • Delicacy
  • Exquisiteness
  • Elegance

精致优雅 高雅 精确 完美 精巧

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SLIDE 27

“What Is EP?”

  • Precision
  • Perfection

Cure Satisfaction

  • Delicacy
  • Exquisiteness
  • Elegance
  • Destructiveness
  • Nastiness
  • Massiveness
  • Excessiveness

Deviating

  • Reckless

粗糙 邋遢 毁坏 多余 鲁莽

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SLIDE 28

When to offer a therapy as first-line?

  • Safety
  • Effectiveness
  • Need from patient
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SLIDE 29

AF Ablation Summary

  • AF ablation is an AF ablation, still.
  • There are many uncertainties.
  • More data is needed.
  • It is still too early to be offered to most

patients as a first-line therapy.

  • Catheter ablation might be the right

answ er for some patients.

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SLIDE 30

“Priority of Care”

  • Rate Control
  • Anticoagualtion
  • Rhythm Control
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SLIDE 31

2/15/06, ER:

58 yo Man, Day Before EPS

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SLIDE 32

Before (12/23/05 08:47:00) After (02/16/06 15:50:55)

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SLIDE 33

What’s New in 2015?

  • Stroke risk assessment: CHA2DS2-VASc
  • New oral anticoagulants:

– Dabigatran – Rivaroxaban – Apixaban – Edoxaban

  • Ablation: targeting substrates
  • Digoxin: associated w ith w orse outcome
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SLIDE 34

Stroke Prevention in 2015

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SLIDE 35

Digoxin is associated w ith bad outcomes

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SLIDE 36

Sinus Rhythm, Not AAD Use, Is Associated With Improved Survival

The AFFIRM Investigators. Circulation. 2004;109:1509-1513.

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SLIDE 37

AF Ablation in 2015 Targeting Substrates

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SLIDE 38

Atrial Fibrosis Is Associated With AF Recurrence

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SLIDE 39

Summary

  • AF is common, w ith different clinical presentations.
  • AF is a complicated arrhythmia and our

understanding regarding the exact mechanism remains limited.

  • Catheter ablation, although based on imperfect

theory, may help selected patients.

  • AF is a manageable arrhythmia, and options are

available for all patients to minimize risks for complications and to improve quality of life.

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SLIDE 40

References

Questions?

541-600-4GUO hguo@ heacehealth.org