Subodh K. Agrawal, MD• Interventional Cardiologist at

Athens Heart Center

• Board Certified in Internal Medicine, CardiovascularDiseases, Interventional Cardiology, and Sleep Medicine

• Special interests are coronary artery disease, sleep disorders and their connection to cardiac function, healthcare education, and finding ways to help reducecosts while improving the quality of healthcare in the U.S.

Medical School:Sawai Man Singh Medical College

Residency:Emory University

Hospital

Fellowship: Emory University

Hospital

Synergy

Atrial Fibrillation (Defined)

AF is an arrhythmia characterized by uncoordinated atrial activation, with consequent deterioration of atrial mechanical function

Circulation 2011; 121: e269-e367

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Miyakasa Y, et al. Circulation. 2006; 114:119-125.

Atrial Fibrillation: An Epidemic

16 millionUS Prevalence

1 in 4 lifetime risk in men and women ≥ 40 years old

ParoxysmalSelf-Terminating

PersistentLasts > 7 Days

PermanentCardioversion Failed or Not Attempted

Normal Sinus Rhythm

Atrial Fibrillation

The “3 Ps” and Natural History of Atrial Fibrillation

Paroxysmal AF is as likely to cause stroke aspersistent or permanent AF

Controversies in Atrial Fibrillation

• Rhythm vs rate control• Definition of optimum rate control• Need for early cardioversion to prevent remodeling• Electric vs pharmacological cardioversion• Selection of patient for long term anticoagulation• Warfarin vs novel anticoagulation agents• Ablation therapy how much to ablate• Relationship between mechanism and therapy

We Aim To Move Perception To Reality

Underestimated

AF REALITY

AF is a severe CV disease within the CV continuum

AF has direct morbidity and mortality impact

AF PERCEPTION

An isolated low risk disease requiring symptom

management and stroke prevention

7

Atrial Fibrillation VS Current Management

Interactive Questions

An 82 year old man is in your office for an annual Medicare physical.

What is the chance he has atrial fibrillation?A. 1%B. 5%C. 10%D. 25%

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<55 55-59 60-64 65-69 70-74 75-79 80-84 > 85

WomenMen

Prevalence of Diagnosed AF

Go AS, JAMA. 2001 May 9;285(18):2370-5. Pub Med PMID: 11343485

# Women 530 310 566 896 1498 1572 1291 1132

# Men 1529 634 934 1426 1907 1886 1374 759

Men surpass women in every age range

Stratified by Age and Sex

x-axis = %y-axis = # of men/women

A 46 year old male patient is in for an annual physical exam.

What is his lifetime risk of developing AF?A) 1%B) 5%C) 10%D) 25%

68 year old female with atrial fibrillation, a past history of Myocardial infarction, and no other co-morbidities. How would you classify her stroke risk?

What is her CHADS2 score?A) 0B) 1C) 2

What is her CHA2DS2-VASc score?A) 1B) 2C) 3

AF PIEFUTURE

AF PIE PAST

Fuster V. Circulation 2012; epubl April 18

78 year old male with atrial fibrillation and hypertension (CHADS2 score = 2 [4% stroke rate per year]).

What is his annual major bleeding rate?A) 1%B) 2%C) 3%D) 5%E) 10%

• 78 year old female with atrial fibrillation, hypertension and CHF.

• CHADS2 = 3 • CHA2DS2-VASc = 5 • HAS-BLED = 2

What would you use for stroke prevention?A) No anti-thromboticsB) AspirinC) Aspirin + clopidogrelD) VKA antagonistE) Dabigatran or Rivaroxaban

69 year old lady with palpitation. Holter revealed transient AF lasting for 3-10 minutes with rate of 140 to 150, otherwise NSR. She has history of stroke in the past of an unknown origin, from which she has recovered completely.

What should you do?A) Start rate control and anticoagulationB) Start rhythm control and anticoagulationC) Start ASA

A 71-year-old white female with a history of chronic, non-valvular AF, controlled hypertension, and a history of mild congestive heart failure has been evaluated by a cardiologist and found to be a non suitable candidate for warfarin therapy. Due to logistical barriers that make monitoring difficult and dietary variations, the patient has had difficulty controlling her INR.

What should you do?A) Replace Warfarin with aspirinB) Replace Warfarin with aspirin + clopidogrelC) Replace Warfarin with a non-monitored oral

anticoagulant

• An 81-year-old white female with a history of chronic, non-valvular AF, a history of a previous ischemic stroke, and a history of mild congestive heart failure has been on a combination of clopidogrel and aspirin therapy because she was found to be intolerant of warfarin. She is admitted to the hospital for a GI bleed, and is found to have a hematocrit of 29 and a hemoglobin of 9.8. A bleeding colon poly resected and no further GI bleeding occurred and patient HCT normalized. The aspirin and clopidogrel are discontinued. The patient stabilizes, and the cardiologist is consulted to determine the subsequent course of her antithrombotic treatment. She has a HAS-BLED score of 3.

Which of these better describes your opinion?A) Because of the documented GI bleed, the patient should not be treated

with antithrombotic agents, because the risk of bleeding outweighs the risk of stroke and its complications.

B) Because of the patient's risk profile, there should be an attempt to provide thromboprophylaxis against embolic stroke.

At this point you would most likely:A) Try the patient on warfarin againB) Try to re-introduce clopidogrel and aspirinC) Treat the patient with aspirin aloneD) Introduce a non-monitored oral

anticoagulant to the patient's regimen.