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 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.
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
ECG @ 9:40 am 4/26/07
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
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.
Atrial Fibrillation Is Common
Atrial Fibrillation Demographics by Age U.S. population Population with AF x 1000 x 1000 Population with 30,000 500 atrial fibrillation 400 U.S. population 20,000 300 200 10,000 100 0 0 <5 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 90- >95 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 94 Age, yr Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.
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!
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
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
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.
Are all AFs the same? • Paroxysmal – terminates spontaneously w ithin 7 days of onset • Persistent – sustained > 7 days – longstanding persistent: c ontinuous AF > 12 months duration. • Permanent • Lone AF
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.
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
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%
CHA 2 DS 2 -VASc Risk factor score C 1 Conge stive he ar t failur e / L V dysfunc tion H 1 Hype r te nsion Age ≥75y A 2 2 D 1 Diabe te s me llitus S 2 2 Str oke / T IA/ T E Vasc ular dise ase (pr ior myoc ar dial infar c tion, V 1 pe r iphe r al ar te r y dise ase , or aor tic plaque ) A 1 Age 65-74y Sc 1 Se x c ate gor y (ie fe male ge nde r ) 9 Maximum Sc or e maximum sc o r e is 9 sinc e age may c o ntr ubute 0, 1, o r 2 po ints L ip GY, e t a l., Che st 137, 263-272, 2010
CHA 2 DS 2 -VASc – overall event rates Stroke and systemic embolism %/year 6 5 4 3 2 1 0 0-1 2 3 4 5 6 7 8-9 CHA 2 DS 2 -VASc No of patients 634 3408 5365 4378 2566 1185 451 125
Marine JE. JAMA. 2007; 298(23): 2368-2778
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
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%
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
Catheter Ablation: How Is A Cure Delivered? Conventional AF Ablation • Mechanism? • Better understanding of mechanism – Microreentry – Multiple w avefronts • Fixed circuits or foci – No fixed circuit • Target: substrate – Triggers Atrial flutter • Target(s): AVNRT – Triggers? WPW – Drivers? Focal atrial tachycardia – Substrate? VT – Autonomic nerves?
“ What Is EP?” 精致优雅 • Exquisiteness 精确 高雅 • Elegance • Precision 精巧 完美 • Delicacy • Perfection Cure Satisfaction
“ What Is EP?” 粗糙 • Massiveness 邋遢 鲁莽 • Nastiness • Reckless • Excessiveness • Destructiveness 多余 毁坏 • Exquisiteness Deviating • Elegance • Precision • Delicacy • Perfection Cure Satisfaction
When to offer a therapy as first-line? • Safety • Effectiveness • Need from patient
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.
“Priority of Care” • Rate Control • Anticoagualtion • Rhythm Control
2/15/06, ER: 58 yo Man, Day Before EPS
Before (12/23/05 08:47:00) After (02/16/06 15:50:55)
What’s New in 2015? • Stroke risk assessment: CHA 2 DS 2 -VASc • New oral anticoagulants: – Dabigatran – Rivaroxaban – Apixaban – Edoxaban • Ablation: targeting substrates • Digoxin: associated w ith w orse outcome
Stroke Prevention in 2015
Digoxin is associated w ith bad outcomes
Sinus Rhythm, Not AAD Use, Is Associated With Improved Survival The AFFIRM Investigators. Circulation. 2004;109:1509-1513.
AF Ablation in 2015 Targeting Substrates
Atrial Fibrosis Is Associated With AF Recurrence
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.
References Questions? 541-600-4GUO hguo@ heacehealth.org
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