got rhythm? - memorial hermann health...
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Got Rhythm? Ramesh Hariharan, MD, FHRS
Professor of Cardiology UTHealth Medical School Medical Director of Cardiac Electrophysiology Memorial Hermann Heart & Vascular Institute-TMC
Logical conclusions! • Conflicting medical studies: • The French eat a lot of fat and also suffer fewer heart
attacks than the British or Americans. • The Italians drink excessive amounts of red wine and
also suffer fewer heart attacks than the British or Americans.
• The Germans drink a lot of beer and eat lots of sausages and suffer fewer heart attacks than the British or Americans.
• CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you!
Jason Collier, Center for the Hawks, died October 2005 in his sixth year in the NBA.
Sudden Cardiac Death
Sudden Death Thomas Herrion
• 23 years old • 6’3” • 330 lbs • Offensive lineman • Died shortly after the
Niners touchdown drive Aug 2005
The impact of Sudden Cardiac Death
• Percentage of patients surviving to return to NORMAL day-to-day activities is around 1%
Outcome of SCD
Survival Mortality Ventricular
Tachyarrhythmias Other
Causes of SCD
Wireless Efficiency at Home
• Alleviate patient compliance issues
• Pre-program automatic scheduled transmissions
• Automatic alert notification with physician-selected CareAlerts
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Now playing at an ER near you: “ My ICD emailed my EP doctor, and he asked me to come to the ER.”
Novel household terms
• Atrial fibrillation • Warfarin • Pradaxa • Xarelto • Eliquis
• Ablation • Wireless Defibrillator
The Problem of AF gets Larger • Number of AF patients likely
increases 2.5-fold in 50 yrs1,2 • Reflects growing proportion of
elderly individuals3
– Due to an ageing population
– Improved survival of patients with conditions which predispose AF (e.g. heart attack)
1. Go AS, et al., Prevalence of diagnosed AF in adults: national implications for rhythm mgt & stroke prev.: ATRIA Study. JAMA 2001;285:2370-5
2. Miyasaka Y, et al., Secular trends in incidence of AF in Olmsted County, MN, 1980-2000, implications on projections for future prevalence. Circulation 2006;114:119-25
3. Briffa T, et al., Long term survival after evidence based treatment of acute MI and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005. BMJ 2009;338:b36
Projected number of persons with AF2
Projected number of persons with AF in the US between 2000 – 2050 No further increase in age-adjusted AF
incidence (solid curve) A continued increase in incidence rate as
evident 1980 - 2000 (dotted curve)
Stroke • Over 15 million strokes worldwide1
– 5 million fatal – 5 million permanently disabled
• Europe averages approximately 650,000 deaths due to stroke each year2
– 3rd leading cause of death behind heart disease and cancer1
– 1st cause of serious long-term disability1
• Stroke social cost accounts approximately for the 3% of total health care expenditures3
1. World Health Report 2004 2. Roger, et al, Heart Disease and Stroke Statistics − 2011 Update: a Report From AHA. Circulation. 2011;123:e18-e209 3. Evers, et al, International comparison of stroke cost studies. Stroke. 2004;35:1209-1215
Risk Factors for Stroke and Thrombo-embolism
‘Major’ risk factors ‘Clinically relevant non-major’ risk factors
Previous stroke, or TIA, or systemic embolism
Age > 75 years
Heart failure or moderate to severe LV systolic dysfunction (e.g. LV EF < 40%)
Hypertension Diabetes mellitus Female sex Age 65–74 years Vascular disease
Camm, et al., ESC 2010 Guidelines for the management of Atrial Fibrillation; European Heart Journal doi:10.1093/eurheartj/ehq278
What do latest the guidelines say? • Fundamentally: everyone with AF and one risk factor should be on
anticoagulation therapy – “Recommendations for antithrombotic therapy should be based on the
presence (or absence) of risk factors for stroke and thrombo-embolism” • Assessment of bleeding risk should be part of the patient assessment before
starting anticoagulation – Bleeding risk assessment: ‘high risk’: some caution and regular review of
the patient is needed following the initiation of antithrombotic therapy, whether with VKA or aspirin.
Camm, et al., ESC 2010 Guidelines for the management of Atrial Fibrillation; European Heart Journal doi:10.1093/eurheartj/ehq278
Rat poison?
• Cows dying after dehorning • Bulls dying after castration • Canadian veterinary concerns • Karl Link, Univ of Wisconsin • Wiconsin Alumnus Research
Foundation ARIN
Country Distribution of Mean Time in Therapeutic Range in the RE-LY Trial
• 5791 Patients on warfarin • Major variations between countries
– Europe: about 3 out of 10 patients out of therapeutic range – Sweden: 23% out of range – Taiwan: 56%
Wallentin, et al., Efficacy and safety of Dabigatran compared with Warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial; The Lancet, 2010: 376; 975 - 983
Advances in Anticoagulant Therapy • Coumadin-greater use of home monitoring
– Target INR in trials 55-64% of the time.
• Dabigatran –PRADAXA 150/110/75 mg BID – RELY trial
• Rivaroxaban-XARELTO 20/15/10 mg QD – ROCKET AF
• Apixiban-ELIQUIS 5mg PO BID – ARISTOTLE
• Edoxaban-LIXIANA 60/30 mg QD – ENGAGE AF-TIMI48
• Betrixiban
• 10-12% mortality reduction • 21% reduction in
stroke/systemic embolism • 31% reduction in major
bleeding episodes When compared with Warfarin
The WATCHMAN® product is a device for percutaneous closure of the left atrial appendage
• Five sizes of device (21, 24, 27, 30 and 33 mm) allow for precise fit within ostium
• It is implanted via a transseptal approach by use of a catheter-based delivery system
• The delivery catheter is capable of recapturing the device if necessary
• Received CE mark in 2005
• WATCHMAN is a self-expanding nitinol frame with fixation anchors and a permeable fabric cover
• It is designed to be permanently implanted at or slightly distal to the opening of the LAA to trap potential emboli before they exit the LAA
WATCHMAN® LAA Closure Device Images on file at Boston Scientific Corporation
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