Presentation on theme: "Atrial Fibrillation in the Era of the Accountable Care Organization"— Presentation transcript:
1Atrial Fibrillation in the Era of the Accountable Care Organization John Windle MD October 18, 2013Professor and Chief of CardiologyUniversity of Nebraska Medical Center
2“Ha ha ha, Biff. Guess what “Ha ha ha, Biff. Guess what? After we go to the drugstore and the post office, I’m going to the vet’s to get tutored.”
3Conflict of InterestI have no relevant conflicts. Just lots of opinions
4Atrial Fibrillation in the Era of the Accountable Care Organization A Quick Review of the BasicsThe importance of DefinitionsThe importance of atrial transportThe clinical trials that drive the guidelinesFilling in the GapsRate Control versus Rhythm Control issuesPerspectives on bleeding versus stroke but not discussing new therapies.Musings on how this might work in an ACO model
5Atrial FibrillationMost common sustained symptomatic tachyarrhythmia. Over 3,000,000 Americans suffer from atrial fibrillation.Incidence with age and presence of structural heart diseaseSlightly more common in men than women15%(75,000 per year) of all strokes occur in AF patientsOne of the top causes of hospitalizations and extension of stays in HospitalsBialy et al. Journal of the American College of Cardiology 1992; 19(3):41A.Prystowsky et al. Circulation. 1996; 93(6):Wolf et al. Archives of Internal Medicine. 1987; 147(9):
6Incidence of Atrial Fibrillation (Framingham Study) Chronic AFParoxysmal AF14-12-10-8-6-4-2-0-14-12-10-8-6-4-2-0-12.912.7MenWomenMenWomen9.22-yr Incidence (per 1000)2-yr Incidence (per 1000)22.214.171.124.126.96.36.199.188.8.131.52.50.70.5--------30-3940-4950-5960-6970-7930-3940-4950-5960-6970-79AgeAgeKannel et al. American Heart Journal. 1983;106(2):
7Consequences of Atrial Fibrillation Arrhythmia-associated symptoms, look at exertional symptoms of shortness of breath, exertional dyspnea and decreased exercise tolerance. LV function: Impact of atrial transport and diastolic function.Tachycardia-mediated cardiomyopathy (heart rates over 130 b/m)2-fold in cardiac mortality5-fold in risk of stroke
8“Why do I feel like crap?” Myocardial and Hemodynamic Consequences of Atrial fibrillationLoss of atrial contraction decreases cardiac output9% drop in C.O. in canine model15% drop in C.O. in irregular response vs. same average rate pacing.Decrease in coronary blood flow with irregular ventricular rhythm.Tachycardia-induced cardiomyopathy (heart rate >130 for several weeks).LVH (diastolic dysfunction) accentuates the importance atrial contraction.
9The impact of atrial contribution by cardiac doppler
10Atrial Fibrillation-The 3 Ps Paroxysmal-Self-limited, often occurring in structurally normal heartsPersistent-Requiring intervention, either chemical (antiarrhythmic drugs) or electrical to restore sinus rhythmLong-standing persist-a term created by cardiac electrophysiologists to “not give up”.Permanent-”Uncardiovertable”
12Paroxysmal Atrial Fibrillation Vasovagal-nocturnal, triggered by stress, meals or alcoholSelf-limited but shortened duration with propafenone or flecainideOften have pulmonary vein fociAmenable to Ablative therapy
13Persistent Atrial Fibrillation Need an intervention to restore sinus rhythmMore likely to involve structural heart disease: Cardiac effects of hypertension and LVH, prior myocardial damage such as MITry to figure out the symptom trigger: Rate, regularity or Atrial synchrony and atrial transport.
14Permanent Atrial Fibrillation Un-cardiovertable atrial fibrillationDurationLeft atrial sizeComorbiditiesAbsence of Symptoms
15Decision Points for Atrial Fibrillation Prevention of ThromboembolismVentricular Rate ControlConversion to NSRMaintenance of NSRShort TermLong TermTimeNSR = normal sinus rhythm
16Rate Control Therapy A-V Nodal Agents (slow ventricular response) Digoxin-increases vagal tone, reduces resting heart rate but not exercise rateBeta Blockers-underutilized but most effectiveCalcium Channel AgentsDiltiazem and verapamil not nifedipineAdenosineA-V Node Ablation with pacemaker placementSingle versus Bi-V device
17Rhythm Control Therapy Atrial Muscle Agents (restoration and maintenance of sinus rhythm)Procainamide and Quinidine-What we learned about in School but of limited use and availability nowPropafenone, Flecainide-Good for acute conversion and normal hearts (Pill-in-the Pocket)Disopyramide-Still in good option for some, decreases vagal toneSotalol and Dofetilide-Torsades de Pointes but otherwise great agentsDronederone-very limited use.Amiodarone**The Vaughn-Williams Classification system is easy but wrong.
18The Affirmed TrialThe Affirmed Trial-Rate Control versus Rhythm Control in Patients with Atrial FibrillationCritical Study: Randomized Control TrialRhythm Control no better than Rate ControlRate control less costly
19The Affirmed Trial: Part II Short follow-up on “elderly”, asymptomatic patientsBased on an “intention to treat”“Failure” based on first recurrence versus time spent in desired rhythmVery high overlap in assigned patients in their actual rhythm (sinus rhythm versus atrial fibrillation).Not a comparison of atrial fibrillation versus sinus rhythm (The sinus rhythm patients did significantly better)
20Atrial Fibrillation; now what?! No significant improvement in quality of life with “rhythm control” strategy in multiple trials above. STAF and HOT CAFÉ showed increase in exercise tolerance.
21It’s just AF; it won’t KILL ME. Excess mortality in AF patients compared to matched (non-AF).HF promotes AF, AF exacerbates HF, and patients with either who develop the other, share a poor prognosis.Stroke in AF averages 5% per year!1.5% annual in 50-59y to 23% annual in yrs.Framingham Heart Study (1983);The Regional Heart StudyWhitehall StudyManitoba Study (1995)Framingham Data.
22My Take Home Messages:Yep-Sinus rhythm and rate controlled atrial fibrillation equivalent in asymptomatic, elderly patients followed over 3-5 years.Yep-Lower utilization of resources with rate control strategyBut,Didn’t answer sinus versus rate controlMost of my patients are not truly asymptomaticAtrial fibrillation causes a 5-10% drop in EF in most patients, what do you think will happen over time?
23AnticoagulationAnticoagulation is recommended for ALL patients with atrial fibrillation, except those with “LONE AF” or contraindications. Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor Aspirin mg for low-risk patients, or those with CI to oral anticoagulation Anticoagulation for atrial flutter is recommended as per AF. Long term anticoagulation with vitamin K antagonist is NOT recommended for primary strike prevention in patients <60 yrs of age without heart disease.CHADS2 ScoreEF <35%
29Catheter Ablation for AF Rationale:Triggers within the pulmonary veins and other sites (SVC, LM, CS, CT)Isolation of the pulmonary veins eliminates AF in many patients with PAF.Alteration of substrate in Persistent AF patients dramatically reduces symptoms of AF, and frequently reduces or eliminates the need for antiarrhythmic medications to control the rhythm.
30History of AF AblationInitial procedure mimicked the surgical maze procedure. Success rate was 40-50% and complication rate high. (Prior to 1998).Automaticity within the pulmonary veins was then the target…
31Pulmonary Vein Isolation ~95% of the triggers for AF are suspected to be in the pulmonary veins.Additional triggers at sites of “Complex Fractionated Atrial Electrograms” (CFAEs)In PAROXYSMAL atrial fibrillation, pulmonary vein isolation is effective in 80-85% of cases at “CURING” atrial fibrillation.Currently, “Symptomatic atrial fibrillation refractory to or intolerant of medical therapy” is the primary indication for PVAI.
32Ultrasound Reconstruction of The Left Atrium with CartoSound/ICE WHAT FOR:Mapping veins, appendageMitral annulus/valveVelocities, evaluate for PFOMap coronary arteriesCONTINUOUSLY EVALUATEFOR PERICARDIALEFFUSION
36Atrial fibrillation persists within the RSPV, but sinus rhythm is present elsewhere
37What about “Non-Paroxysmal” AF? More complex disease entity from an ablation standpoint.PVAI is not sufficient for elimination of atrial fibrillation in many patients.Additional lesions include approximation of the maze lesion set with ablation at the roof, mitral annulus, cavotricuspid isthmus, and svc.The addition of CFAE ablation is of unclear benefit and remains controversial.
38Complications: Perforation with pericardial tamponade ~1% of cases of PVAI (up to 5% depending on series)Usually self-limiting, requiring a drainRarely can require surgical drainage/repair.Cerebrovascular accidents0.5 to 2.5% of casesDramatically reduced with higher ACTPhrenic Nerve Injury0.1 to 0.48% of casesRecovery in 66% of cases, can be permanentRadiation relatedFluoroscopy times can be prolonged.Pulmonary vein stenosis1 to 2% with current techniques(15-20% historically)Atrio-Esophageal fistula
39New Ablation Tools and Techniques CryoBalloon (Arctic Front)Ablation Frontiers CatheterHigh-Intensity Focused UltrasoundLaser ablationAnd more…. Just around the corner.
40Where Do We Go From Here?3,000,000 patients how do we divide up the work?Base-rate theory: EP>Cardiology>Primary CareTeam-based CareDecision-makingRate versus rhythm controlAntithrombotic Care
41Where do we go from here: the ACO In my “perfect-world”EP physicians would consult (either actual or virtually) on all patients at presentation of their atrial fibrillationThe EP physician, the primary care provider and the patient would develop a consensus treatment plan with all three holding accountability for the outcome.If anti-thrombotic therapy was initiated it would be managed by a non-physician team member under protocol.Cardiologists would be involved in atrial fibrillation management.
43New Drugs Dronedarone: a non-iodinated amiodarone analog. Trials have compared the medication to placebo and amiodarone.Euridis and Adonis (European and American) trials showed efficacy relative to placebo.ANDROMEDA study showed higher death rate in NYHA Class IV patients.ATHENA trial demonstrated stroke risk reduction.Currently, approval is for “treatment of patients with a history of, or recurrent atrial fibrillation to reduce their risk of cardiovascular hospitalization due to this condition.”
44Azmilide Not yet approved Potassium blocker similar to dofetilide or sotalol, but blocks both iKr and iKs.Does not perform as a beta-blocker.LONG HALF-LIFE of up to 4 days.In a trial to assess its efficacy in MI patients with EF 15-35%, (ALIVE), a higher proportion of patients in the treatment arm were in sinus rhythm at the end of the study…Placebo-controlled trial is in the works.