atrial fibrillation 21 challengesvfustercourse.com/assets/pdfs/ponencia8.pdfgroup 3-d-adjusted...
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Molecular (M), Clinical (C) and Population (P)Bases of Cardiovascular Disease and Health
16 and 17 July 2018 / 16 y 17 de julio de 2018Cardona (Barcelona, Spain) – Auditori Valentí Fuster
Atrial Fibrillation 21 Challenges
MCP BASES OF MYOCARDIAL & STRUCTURAL DISEASE, 2019
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Molecular (M), Clinical (C), Population (P)Bases of Cardiovascular Disease and Health, 2019
3. MCP of Rhythm, Myocardial & Structural Disorders
9. Atrial Fibrillation 21 Challenges
10. Genetics, Omics & Cardiomyopathies at Full Speed
11. Myocardial Tissue Regeneration in Controversy
12. Structural Valvular Heart Disease in Motion
4. Bases of My Academic (Creative) Future
13. A View of my Professional Life. Where I am Going?
Cardona, July 16, 2019 No Disclosures
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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1. EHJ 2016; 37:2893 - SimpleObesity is Complex
1). Acute Management of AF
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2). Chronic Contributor & Management Epicardial Fat
CX Wong et. al. Eur Heart J. 2017;38:1294
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3). Trigger - Post-Operative AF Thromboembolism Compared With Nonvalvular AF
JH Butt et. al. J Am Coll Cardiol 2018;72:2027 – Danish Reg. (15,000 vs 4000)
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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TJ Bunch et. al. Eur Heart J. 2016;37:2890BW Calenda, V Fuster, V Reddy et. al. Nat Rev Cardiol 2016;13:549
1). Myocardial Pathogenesis of AF
Alcohol
Genetics
Aging
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TJ Bunch et. al. Eur Heart J. 2016;37:2890BW Calenda, V Fuster, V Reddy et. al. Nat Rev Cardiol 2016;13:549
Myocardial Pathogenesis of AF
Alcohol
Genetics
Aging
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S Nattel et. al. Nat Rev Cardiol. 2016; 13: 575.
2) Electrical Pathogenesis of AF At The Pulmonary Veins
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S Nattel et. al. Nat Rev Cardiol. 2016; 13: 575. – Also Re-entry
Molecular Mechanisms of Focal Ectopic Firing In Paroxysmal AF
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3). Natural History of AF
JB Guichard et. al. J Am Coll Cardiol 2017;70:756
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LA Tissue Fibrosis on 3D LGE CMR Scans
JB King, N Marrouche et. al. J Am Coll Cardiol 2017;70:1311
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JAMA. 2014;311(5):498
Fibrosis of the LA Wall, Blinded To The Treating Physicians:
Stage 1 (<10% ), Stage 2 (≥10%-<20%),Stage 3 (≥20%-<30%), Stage 4 (≥30%).
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: How/When//Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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1a). Atherothrombotic and Atheroembolic Diseases
J Narula, V Fuster et. al. J Am Coll Cardiol 2019;73:1000
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How?, Coagulation Cascade and Oral Anticoagulation
FWA Verheugt, CB Granger et. al. J Am Coll Cardiol 2019;74:699
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Thrombin & Platelet Activation
FWA Verheugt, CB Granger et. al. J Am Coll Cardiol 2019;74:699
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1b). AC When ?- The Prevention of Stroke .
V Fuster, JS Chinitz, Circ. 2012 ; 125: 2285Swedish AF Cohort Register (L Friberg, GYH Lip et al) Circ. 2012; 125: 2298CHA2DS2VASc: ESC Guidelines (P Kirchhof, AJ Camm et al ) 2013 - ACC / AHA / HRS 2014 A/C Prevention - Emboli >>> Bleeding, Thrombosis > Bleeding
?
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1c). To Bridge & How to Bridge for DOACs/VKAs
JU Doherty, JL Januzzi et. al. J Am Coll Cardiol 2017;69:872 - Exeptions OnlyORBIT=AF (BA Steinberg et al.), Circulation 2015; 131:488 –
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2). LAA Structure / Function – Stroke in NSRCardiac Imaging For Assessment
J Romero et. al. Nat Rev Cardiol. 2014;11:470ENGAGE AF (DK Gupta et al.) EHJ 2014; 35:1457 – LA Function / NSR ?ASSERT (M Brambatti, et al.) Circ. 2014; 129:2094- LV Function / NSR ?IMPACT (DT Martin et al.) EHJ; 2015; 36:1660- LV Function / NSR ?
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3). Silent Cerebral Infarcts (SCI) Cardiac Disease And Procedures
ME Hassell et. al. Nat. Rev. Cardiol. 2013;10:696F Gaita et. al. J Am Coll Cardiol 2013;62:1990 (Italy)S Kalantarian et. al. Ann Intern Med. 2014;161:650 – 15 Studies, SCI
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Decline In The Global Cognitive Score Function of AF
A Singh-Manoux et. al. Eur Heart J. 2017;38:2612F Gaita et. al. J Am Coll Cardiol 2013;62:1990 (Italy)S Kalantarian et. al. Ann Intern Med. 2014;161:650
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AF, Cognitive Decline, and DementiaVia Different Mechanisms
HC Diener, GYH Lip et. al. J Am Coll Cardiol 2019;73:612
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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1). AF & PCI in the Era of Vitamin K Antagonists:WOEST & ISAR-TRIPLE
D Capodanno, DJ Angiolillo et. al. J Am Coll Cardiol 2019;74:83
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2). AF & PCI in the Era of DOACs: PIONEER AF, RE-DUAL PCI, and AUGUSTUS
D Capodanno, DJ Angiolillo et. al. J Am Coll Cardiol 2019;74:83
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PIONEER AF-PCI (CM Gibson et. al. ) NEJM 2016;375:2423
Preventing Bleeding in Pts with AF-PCI
Group 3 - D-adjusted vitamin K antagonist plus DAPT for 1, 6, or 12 months.Group 2 - VLD rivaroxaban (2.5 mg twice daily) plus DAPT for 1, 6, 12 MoGroup 1 - LD rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor for 12 Mo
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PIONEER AF-PCI (CM Gibson et. al. ) NEJM 2016;375:2423
Group 3 - D-adjusted vitamin K antagonist plus DAPT for 1, 6, or 12 months.Group 2 - VLD Rivaroxaban (2.5 mg twice daily) plus DAPT for 1, 6, 12 MoGroup 1 - LD Rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor for 12 Mo
CV Events in Pts with AF-PCI
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3). AF & PCI in the Era of DOACs: Consensus Recommendations on Management
D Capodanno, DJ Angiolillo et. al. J Am Coll Cardiol 2019;74:83
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs1: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3) 1LAAC
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1). Annual Stroke Risk and Risk Reduction With Various Preventative Strategies in AF
M Alkhouli, DR Holmes et. al. J Am Coll Cardiol 2018;71:2790
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Relative Differences In Efficacy And Safety Outcomes Between NOACSs And Warfarin
D Lakkireddy et. al. J Am Coll Cardiol 2019 (Submitted)
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Doses Of The Different NOACsIn The 4 Large Trials In AF Patients
HC Diener et. al. Eur Heart J. 2017;38:860
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Annual Stroke Risk and Risk Reduction With Various Preventative Strategies in AF
M Alkhouli, DR Holmes et. al. J Am Coll Cardiol 2018;71:2790
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Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation
M Alkhouli, DR Holmes et. al. J Am Coll Cardiol 2018;71:2790
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Stroke Prevention in AF With LAA Closure
PREVAIL and PROTECT AF (VY Reddy et. al.) J Am Coll Cardiol 2017;70:2964
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KE Chan et. al. J Am Coll Cardiol 2016;67:2888YC Lau et. al. J Am Coll Cardiol 2016;68:1452 – Apixaban 2.5mg BID
2). Renal Function - Warfarin & NOACs
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Pharmacokinetic and Primary Routes of Clearance of Oral Anticoagulant Agents in Liver
A Qamar et. al. J Am Coll Cardiol 2018;71:2162
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VHD-AF, Patients on Edoxaban or Warfarin in the ENGAGE AF-TIMI 48 Trial
VHD was defined as history or baseline echo evidence of at least moderate aortic/mitral regurgitation, aortic stenosis, or prior valve surgery -bioprosthesis replacement, valve repair, valvuloplasty. Excluded from the trial, patients with moderate to severe mitral stenosis or mechanical heart valves. Comparisons were made of rates of stroke/systemic embolic event (SSEE) & major bleeding.VHDincreased the risk of death, major adverse CV events, and major bleeding but did not affect the relative efficacy or safety of higher-dose edoxaban versus warfarin in AF.
R De Caterina et al., J Am Coll Cardiol 2017; 69:1372CT January et. al. J. Am. Coll. Card. 2014;64:e1 – No Dabigatran in Mechanical HV
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Mitral Stenosis and AF, DOACs vs Warfarin
JY Kim, TH Rho et. al. J Am Coll Cardiol 2019;73:1123
The study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea. A total of 2,230 patients (mean age 69.7) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group.
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3). Reversal Agents For NOACS
JH Levy et. al. Nat Rev Cardiol. 2018;15:273
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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1). Types of Catheter Ablations In Sweden Between 2006 And 2015
F Holmqvist, P insulander et. al. Eur Heart J. 2019;40:820
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Probability of Repeat Ablation (Same Arrhythmia) After A De Novo Ablation
F Holmqvist, P insulander et. al. Eur Heart J. 2019;40:820
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Atrial Fibrillation BurdenFrom Implantable Cardiac Monitor
C Blomström-Lundqvis, D Mörtsell et. al. JAMA. 2019;321:1059
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CHA2DS2-VASc (Recurrent AF) in Predicting Clinical Outcomes in AF After Catheter Ablation
T-F Chao et al., JACC 2011; 58:2380 (Japan) – 565 Pts
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AF Burden - After Catheter AblationSeveral Strategies (Linq Recorder etc)
EI Charitos et. al. Circulation. 2012;126:806 (Luebeck, Germ.)
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Cumulative Hazard Rates Of Embolic Events According To The Pattern Of AF Occurrence
T Vanassche, SJ Connolly et. al. Eur Heart J. 2015;36:281
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2). AF - Catheter Ablation vs AntiarrhythmicTherapyon Mortality, Stroke, Bleeding, & Cardiac Arrest
This is an investigator-initiated, open-label, multicenter, randomized trial involving 126 centers in 10 countries. A total of 2204 symptomatic patients with AF aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke were enrolled from November 2009 to April 2016, with follow-up through December 31, 2017. Among patients with AF, the strategy of catheter ablation vs medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest.However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers
CABANA (DL Packer, KL Lee et al., JAMA 2019; 321:1261)
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CABANA AF Incidence Primary End Point by ITT
DL Packer, KL Lee et. al.) JAMA 2019;321:1261
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CABANA AF1ary End Point by Per-Protocol Analysis (AT)
DL Packer, KL Lee et. al.) JAMA 2019;321:1261
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CABANA AFAll-Cause Mortality & Mortality / CV Hosp by ITT
DL Packer, KL Lee et. al.) JAMA 2019;321:1261
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CABANA AFRecurrent AF Post Blanking by ITT (AT)
DL Packer, KL Lee et. al.) JAMA 2019;321:1261
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Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With AF
In this randomized trial of 2204 patients with AF, catheter ablation vs conventional medical therapy, significantly improved quality of life at 1 year as measured by the AF Effect on Quality of Life score and the Mayo AF-Specific Symptom Inventory frequency score, and severity score.
DB Mark, DL Packer, et al., JAMA 2019; 321:1275
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AF Effect on Quality of Life (AFEQT) Summary Scores
CABANA (DB Mark, DL Packer et. al.) JAMA 2019;321:1275
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Mayo AF–Specific Symptom Inventory (MAFSI) Frequency Scores
CABANA (DB Mark, DL Packer et. al.) JAMA 2019;321:1275
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Effect of Catheter Ablation vs Antiarrhythmics on Quality of Life in AF
Randomized clinical trial at 4 university hospitals in Sweden and 1 in Finland of 155 patients aged 30-70 years with more than 6 months of AF and treatment failure with 1 antiarrhythmic drug or β-blocker, with 4-year follow-up. Pulmonary vein isolation ablation (n=79) or previously untested antiarrhythmic drugs (n=76). Among patients with symptomatic AF despite use of antiarrhythmic medication, the improvement in quality of life at 12 months was greater for those treated with catheter ablation compared with antiarrhythmic medication.
The CAPTAF (C Blomström-Lundqvist, D Mörtsell et al), JAMA 2019; 321:1059
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Observational Study of CABANA-eligible Patients In Both, ITT & As Treated (AT)
AJ Camm. Eur Heart J. 2019;40:1265
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3). Pulmonary Vein Isolation for AFby Pulsed Field Ablation
VY Reddy, P Jais et. al. J Am Coll Cardiol 2019;74:315
In first-in-human trials, PFA preferentially affected myocardial tissue, allowing facile ultra-rapid PV isolation with excellent durability & safety.
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AF - CLINICAL CHALLENGES (21) – 2019
1. Presentation: Simplified vs Insightfulness (3)
2. Pathogenesis: Myocardial vs Electrical (3)
3. AC Rx: When/How/Bridge vs NS-TE / SCI (3)
4. AF / Stent: Triple Rx vs Double Rx (3)
5. AC. / NOACs: Efficacy vs Safety (3)
6. Ablation Yes vs No (3)
7. Screening Screening vs No Screening (3)
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7). Screening for Atrial Fibrillation
B Freedman et. al. Circulation. 2017;135:1851
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Molecular (M), Clinical (C), Population (P)Bases of Cardiovascular Disease and Health, 2019
3. MCP of Rhythm, Myocardial & Structural Disorders
9. Atrial Fibrillation 21 Challenges
10. Genetics, Omics & Cardiomyopathies at Full Speed
11. Myocardial Tissue Regeneration in Controversy
12. Structural Valvular Heart Disease in Motion
4. Bases of My Academic (Creative) Future
13. A View of my Professional Life. Where I am Going?
Cardona, July 16, 2019 No Disclosures