atrial fibrillation 2018: controversy and consensus · from: 2014 aha/acc/hrs guideline for the...
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Conflict of Interest
• Consultant: Medtronic ; CardioNet
• Institutional Fellowship support:
Medtronic; St Jude
Estimated Probability of Appropriate ICD Therapy
(Primary Prevention) as a Function of Post CRT-D LVEF
From: Manfredi Circulation AE 2013;6:257-264
Screened
N = 7401
Withdrew
n = 71
Enrolled
N = 4060Status Unknown
n = 26
Follow-up
N = 3963
Declined
n = 3341(45%)
AFFIRM Investigators NEJM 2002; 347:1825-33
AFFIRMEnrollment
Rate Versus Rhythm Control in Patients with
A. Fib (AFFIRM)
From: AFFIRM investigators NEJM 2002; 347:1825
“From Stettin in the Baltic to Trieste in the Adriatic,
an iron curtain has descended across the continent.”~ Churchill, March 5, 1946
“From Honolulu in the Pacific to Athens in the Aegean,
the AFFIRM mismessage curtain has descended
across Western medicine.”
If there was a safe and effective
method to restore and maintain
sinus rhythm, would you allow
your patient to remain in atrial
fibrillation?
Quebec, Canada
Population-based Study
of Patients with AF
From: Ionescu-Ittu R et al. Arch Intern Med
2012; 172: 997
Effect on Rhythm vs. Rate Control Therapy
on Mortality Over Time
From: Ionescu-Ittu R et al. Arch Intern Med 2012; 172: 997
Long-term Outcomes in Patients With AF; AF/RFA;
No AF History
From: Bunch TJ et al. J Cardiovasc Electrophysiol 2011; 22:
839
Cognitive Function Evaluation in Controls (green),
Paroxysmal AF (blue) and Persistent AF (red)
From: Gaita et al., JACC 2013; 21: 1990-7
Salutary Effects of Sinus Rhythm on Heart Failure
• Regularization of rhythm
• Physiologic rate control
• Atrial contirbution to cardiac output
Death from Cardiovascular Causes (AF-CHF Trial)
From: Roy D et al. N Engl J Med 2008; 358:
2667-2677
Rhythm Control vs. Rate Control for Atrial Fibrillation and
Heart Failure
From: Roy D et al. N Engl J Med 2008; 358:
2667-2677
From: Hsu L et al. NEJM 2004; 351: 2373-83
Improvement in Left Ventricular Function After Ablation of
Atrial Fibrillation in Patients with Congestive Heart Failure
Patient T.H.
HPI: A 44 y/o man is referred for consideration of CRT
device. He has NIDCM with an LVEF 0.10, NYHA-III
heart failure symptoms, and MDT ICD with MVP.
He has A. Fib with controlled ventricular response.
PE: HR 82/min, irreg; BP 130/60
Lungs - clear
Heart - no S3; no murmur
ECG: A. Fib, rate 84; LBBB; QRS 171 msec
Meds: Carvedilol 25 mg bid; lanoxin 0.125/qd; warfarin;
lisinopril 20 mg qd; diltiazem 60 mg tid
Patient T.H.
• TEE-cardioversion to SR
6 months later:
• ICD: AAIR DDDR 70-120: Ap 95%; Vp 0.4%;
No VT Rx
• ECG: A paced 76/min; LBBB
• ECHO: LVEF 15-20%
• NYHA-I heart failure symptoms
Patient case
• A 60 year old man with 2 years of AF saw me
for a second opinion. Initial CV resulted in
IRAF. He has been in persistent AF with rate
control, and thinks he feels “ok”. Amiodarone
was started and cardioversion was
associated with sinus rhythm and he now
feels “ great with increased energy”.
Proposed Treatment Algorithm for Paroxysmal and Persistent Atrial Fibrillation
From: Prystowsky EN JAMA 2015, 314: 278-288
From: 2014 AHA/ACC/HRS Guideline for the Management of
Patients with Atrial Fibrillation, Circulation, March 28, 2014
Strategies for Rhythm Control in Patients
with Paroxysmal and Persistent AF
Radiofrequency Catheter Ablation to Isolate the Pulmonary Veins and
Rotor Mapping and Ablation
From: Prystowsky EN JAMA 2015, 314: 278-288
Single Procedure Success for Paroxysmal AFRandomized Controlled Trials
Dukkipati, J Am Coll Cardiol. 2015;66:1350-1360
Results spectacular in some patients, dismal in others
Goals of rhythm control
• It is not necessary to eliminate all
episodes of AF
• Minimize frequency and duration of AF
episodes (atrial burden)
• Let the patient be your guide
From: 2014 AHA/ACC/HRS Guideline for the Management of
Patients with Atrial Fibrillation, Circulation, March 28, 2014
Summary of Selected Recommendations for Rate Control
Recommendations
Control ventricular rate using a beta blocker or
nondihydropyridine calcium channel antagonist for
paroxysmal, persistent, or permanent AF.
For AF, assess heart rate control during exertion, adjusting
pharmacological treatment as necessary
A heart rate control (resting heart rate < 80 bpm) strategy
is reasonable for symptomatic management of AF
Lenient rate control strategy (resting heart rate < 110 bpm)
may be reasonable with asymptomatic patients and LV
systolic function is preserved.
COR
I
I
IIa
IIb
LOE
B
C
B
B
From: 2014 AHA/ACC/HRS Guideline for
the Management of Patients with Atrial
Fibrillation, Circulation, March 28, 2014
Coagulation Cascade
Limitations of warfarin therapy
• Routine coagulation monitoring
• Frequent dose adjustments
• Difficulty maintaining stable TTR
• Numerous food-drug interactions
• Numerous drug-drug interactions
Stroke or Systemic Embolism in ROCKET AF
From Patel MK et al. NEJM 2011; 365: 883-91
p < 0.001 for noninferiority
Primary and Safety Outcomes in ARISTOTLE (Apixaban
in A. Fib)
From: Granger CB et al. NEJM 2011; 365:
981-92
Limitations of DOACs
• Expensive
• Avoid use in severe renal disease
• Minimal data in very elderly
• Avoid in certain types of valvular HD
• Use in new onset Afib cardioversion
without TEE requires more data
NOAC vs warfarin: My approach
• Have an in-depth discussion with the
patient concerning the risks/benefits of
various AC approaches
• For the patient who is taking warfarin and
has had stable TTRs and prefers not to
change: Leave well enough alone
• For patients just starting AC who have no
reason to avoid a NOAC: prescribe a
NOAC
From: 2014 AHA/ACC/HRS Guideline for the Management of
Patients with Atrial Fibrillation, Circulation, March 28, 2014
Summary of Selected Recommendations for Prevention of
Thromboembolism in Patients with AF
Recommendations
Antithrombotic therapy based on shared decision-making,
discussion of risk of stroke and bleeding, and patient’s
preferences
CHA2DS2-VASc score recommended to assess stroke risk
With prior stroke, TIA, or CHA2DS2-VASc score >2,
oral anticoagulants recommended. Options include:
- Warfarin
- Dabigatran, rivaroxaban, or apixaban
With warfarin, determine INR at least weekly during
initiation and monthly when stable
COR
I
I
I
I
I
LOE
C
B
A
B
A
From: 2014 AHA/ACC/HRS Guideline for the Management of
Patients with Atrial Fibrillation, Circulation, March 28, 2014
Summary of Selected Recommendations for Prevention of
Thromboembolism in Patients with AF
Recommendations
With nonvalvular AF and CHA2DS2-VASc score of 0, it is
reasonable to omit antithrombotic therapy
With nonvalvular AF and a CHA2DS2-VASc score of 1,
no antithrombotic therapy or treatment with an oral
anticoagulant or aspirin may be considered.
For PCI, BMS may be considered to minimize duration of
DAPT
Following coronary revascularization in patients with
CHA2DS2-VASc score of >2, it may be reasonable to use
clopidogrel concurrently with oral anticoagulants, but
without aspirin.
COR
IIa
IIb
IIb
IIb
LOE
B
C
C
B
Cardioversion of AFTEE Guidance: ACUTE Study Protocol
Klein et al. N Engl J Med. 2001;344:1411-1420.
4 weeks warfarin
Follow-upexamination
AF > 2 days’ duration
Therapeutic A/C at time of TEE
No thrombus
4 weeks warfarin
Repeat TEE
Thrombus persistsNo cardioversion
3 weeks warfarin
Cardioversion
4 weeks warfarin
TEE-guided group n=619 Conventional therapygroup n=603
LA or LAAThrombus detected
4 weeks warfarin
Thrombus resolvedCardioversion
4 weeks warfarin
From: 2014 AHA/ACC/HRS Guideline for the Management of
Patients with Atrial Fibrillation, Circulation, March 28, 2014
Summary of Selected Recommendations for Prevention of
Thromboembolism with Cardioversion of AF and A Flutter
Recommendations
With AF or atrial flutter for >48 h, or unknown duration,
anticoagulate with warfarin for at least 3 wk prior to and
4 wk after cardioversion
With AF or atrial flutter for >48 h or unknown duration
requiring immediate cardioversion, anticoagulate as soon
as possible and continue for at least 4 wk.
With AF or atrial flutter for <48 h and high stroke risk,
IV heparin or LMWH or factor Xa or direct thrombin
inhibitor, is recommended before or immediately after
cardioversion, followed by long-term anticoagulation.
Following cardioversion of AF, long-term anticoagulation
should be based on thromboembolic risk.
COR
I
I
I
I
LOE
B
C
C
C
From: 2014 AHA/ACC/HRS Guideline for the Management of
Patients with Atrial Fibrillation, Circulation, March 28, 2014
Summary of Selected Recommendations for Prevention of
Thromboembolism with Cardioversion of AF and A Flutter
Recommendations
With AF or atrial flutter, for >48 h or unknown duration and
no anticoagulation for preceding 3 wk, it is reasonable to
perform a TEE prior to cardioversion, and then cardiovert
if no LA thrombus is identified, provided anticoagulation is
achieved before TEE and maintained after cardioversion
for at least 4 wk.
With AF or atrial flutter >48 h or unknown duration,
anticoagulation with dabigitran, rivaroxiban, or apixaban is
reasonable for >3 wk prior to and 4 wk after cardioversion.
With AF or atrial flutter <48 h and low thromboembolic risk,
IV heparin, LMWH, a new oral anticoagulant, or no
antithrombotic may be considered for cardioversion.
COR
IIa
IIa
IIb
LOE
B
C
C
Use of ECG Monitoring to Detect AF in Patients after
Cryptogenic Stroke (EMBRACE)
• 572 patients after cryptogenic stroke randomized to
30-day event recorder versus 24-hour Holter monitor
• Event monitor (Braemar) with autodetect AF capability
(over a period of 30 beats)
• Mean age 72 years
• Randomization mean of 75 days after stroke
• 82% of monitored patients completed > 3 weeks
From: Gladstone DJ NEJM 2014; 370: 2467-77
Atrial Fibrillation Detected During Prolonged Ambulatory
Monitoring in Patients with Cryptogenic Stroke (EMBRACE)
From: Gladstone DJ NEJM 2014; 370: 2467-77
Atrial Fibrillation Detected by Implantable Cardiac Monitor in
Patients With Cryptogenic Stroke (CRYSTAL AF)
From: Sanna NEJM 2014; 370: 2478-86
Mass Screening for Atrial Fibrillation (STROKESTOP Study)
• Ongoing study to determine the value of AF screening
in 75-year-old persons and anticoagulant therapy to
reduce stroke over 5 years follow-up
• Monitoring with handheld ECG recorder (Zenicor)
• 30-second ECG rhythm strips twice daily for 2 weeks
and with palpitations
• New AF detected in 218 (3%) of patients
From: Svennberg E Circulation 2015; 131: 2176-84
Patient P-85
HPI: A 88-year-old woman was sent for an electrophysiology
consult because her PCP felt an irregular pulse at a
routine exam. The patient has no cardiac symptoms.
PMH: Hypertension
PE: HR 87 with ectopy; BP 140/90;
Lungs – clear; Heart: ectopy; No m
Ext: +1 bilateral pedal edema
ECG: Sinus rhythm with PACs
Patient P-85
Holter: 984 PACs; several runs of relatively rapid AT-NS
ECHO: LVEF 55-60%
LA 3.9 cm
No LVH
Effect of
Excessive
Supraventricular
Ectopic Activity
(ESVEA) on
Stroke Risk
From: Larsen et al. J Am Coll
Cardiol 2015; 66: 232-41