Practical Approaches to Atrial Fibrillation Management
Transcript of Practical Approaches to Atrial Fibrillation Management
Practical Approaches to Atrial Fibrillation Management
Answers to Your Everyday Questions
H. Mark Guo, MD, FACC, FHRS Clinical Cardiac Electrophysiology Oregon Heart & Vascular Institute
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
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 with ACC D. Cancel cardioversion, titrate BB, start
coumadine, ablation after 3-4 weeks 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 with age to 12% for those > 75 yrs.
• Stroke rate: < 1% to > 15% annually, depending on comorbid risk factors.
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
0
500
400
300
200
100
0
Atrial Fibrillation Demographics by Age
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 wavelets or spiral wave 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 with 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) with multiple premature atrial complexes.
Are all AFs the same?
• Paroxysmal – terminates spontaneously within 7 days of onset
• Persistent – sustained > 7 days – longstanding persistent: continuous AF > 12
months duration.
• Permanent • Lone AF
Are all AFs treated in the same way?
• Hemodynamically unstable: – Immediate cardioversion, sedate if possible – Refractory, IV amiodarone, ibutilide, or procainamide.
• Hemodynamically stable: – Cardioversion: newly diagnosed, onset within 48 hours – Rate control, anticoagulation if indicated – Cardioversion after 3-4 weeks anticoagulation or no
clot on TEE and therapeutic anticoagulation initiated.
Case • 72 yo woman, POD #1 (Ovarian mass removal), ECG
shows AF HR 100-120 bpm, BP 158/66, R 18 • PMH: HTN, and CAD with LCx stented 5 yr ago • What would 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%
Risk factor score
C Congestive heart failure/LV dysfunction 1
H Hypertension 1
A2 Age ≥75y 2
D Diabetes mellitus 1
S2 Stroke/TIA/TE 2
V Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1
A Age 65-74y 1
Sc Sex category (ie female gender) 1
Maximum Score 9
Lip GY, et al., Chest 137, 263-272, 2010
maximum score is 9 since age may contrubute 0, 1, or 2 points
CHA2DS2-VASc
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
0
1
2
3
4
5
6
Atrial Fibrillation Ablation: Success & Repeat Procedures
• 50 – 70% success with a single procedure • Up to 50% will require a second procedure to
achieve success • 50% will have early recurrence within the
first couple days to weeks – 50% of these will resolve within few weeks 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 narrowing 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 Worldwide Survey on the Efficacy and Safety of Catheter Ablation for Atrial Fibrillation
Catheter Ablation: How Is A Cure Delivered?
• Better understanding of mechanism
• Fixed circuits or foci • Target: substrate
• Mechanism? – Microreentry – Multiple wavefronts – No fixed circuit – Triggers
• Target(s): – Triggers? – Drivers? – Substrate? – Autonomic nerves?
Conventional AF Ablation
Atrial flutter AVNRT WPW Focal atrial tachycardia VT
“What Is EP?”
• Precision
• Perfection
Cure Satisfaction
• Delicacy
• Exquisiteness
• Elegance
精致优雅 高雅 精确
完美 精巧
“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
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
answer for some patients.
What’s New in 2015?
• Stroke risk assessment: CHA2DS2-VASc • New oral anticoagulants:
– Dabigatran – Rivaroxaban – Apixaban – Edoxaban
• Ablation: targeting substrates • Digoxin: associated with worse outcome
Sinus Rhythm, Not AAD Use, Is Associated With Improved Survival
The AFFIRM Investigators. Circulation. 2004;109:1509-1513.
Summary
• AF is common, with 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.