Epidemiology and Prognosis Most common sustained arrhythmia 2.2 million in US Last 20 years, 66% increase in admissions for a-fib 0.4-1% prevalence (up to 8% in those older than 80) Incidence: 0.1% per year <40 y/o 1.5-2% per year >80 y/o Prognosis: Increased risk of stroke (5-fold). Increased risk of heart failure (3-fold). Double mortality rate. Diminished quality of life. Possible increased risk of dementia.
Dementia RiskDementia Risk AF indepenently associated with all forms of dementia consecutive patients from large database followed prospectively. (27%) developed AF 1535 (4.1%) developed dementia 5 years follow-up. Mean age 60.6±17.9 years
Dementia Risk cont.Dementia Risk cont. AF independently associated with all dementia. Highest risk of AD was in younger AF group Dementia patients had higher rates of HTN, CAD, CRI, heart failure and strokes. After dementia Dx, presence of AF = higher mortality (HR= ) Bunch et al., Heart Rhythm, 2010, 7: 433.
LAA Occlusion: Amplatzer Cardiac Plug Jain AK, Gallagher S. Percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism: NICE guidance. Heart 2011; 97:762.
LAA Occlusion: Watchman Jain AK, Gallagher S. Technology and guidelines Percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism: NICE guidance. Heart 2011; 97:762.
LAA Occlusion/Amputation. Surgical LAA Amputation (Garcia-Fernandez et al., Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study, JACC, 2003, 42: 1253) 205 patient’s studied retrospectively after mitral valve replacement + LAA amputation. Stroke after 6 years was 3% (vs. 17% for those without LAA amputation. For the most part, standard of care at time of mitral valve surgery in patient with h/o atrial fibrillation. Limited data on stand-alone surgery.
LAA Occlusion/Amputation. Watchman: Protect AF trial Non-inferiority, 700 patients randomized 2:1. CHADS score of 1 or greater. Primary efficacy and primary safety endpoints. Concerns about safety. Not yet FDA approved. Amplatzer Cardiac Plug Lariat LAA amputation: some safety data, limited efficacy data.
Rate and Rhythm ControlRate and Rhythm Control
What should be driver for deciding between rhythm control and rate control strategy? 1.Desire to avoid anticoagulation. 2.Alter long-term prognosis of atrial fibrillation. 3.Control of symptoms related to atrial fibrillation. 4.All of the above.
What should be main driver for deciding between rhythm control and rate control strategy? 1.Desire to avoid anticoagulation. 2.Alter long-term prognosis of atrial fibrillation. 3.Control of symptoms related to atrial fibrillation. 4.All of the above.
Randomized, prospective 4060 patients. Rate control (≤80, ≤110 bpm) Rhythm control Age: 69.7±9.9 1° endpoint: overall mortality Mean f/u 3.5 years Rhythm control associated with more ADRxs, hospitalizations. AFFIRM:
Other Rate vs. Rhythm Trials RACE (Hagens et al., JACC, 2004, 43: 241) 522 patients, 68±9, no difference in composite 1° endpoint. PIAF (Hohnloser et al, Lancet, 2000, 356: 1789) 252 patients, 61±10, no difference in symptoms. STAF (Carlsson et al., JACC, 2003, 41: 1690) 200 patients, 66±8, no difference in composite 1° endpoint. HOT CAFÉ (Opolski et al., Chest, 2004, 126: 476) 205 patients, 61±11, no difference in composite 1° endpoint.
AF and CHF:AF and CHF: 1376 pts (682 vs. 694) EF ≤35% CHF symptoms h/o atrial fibrillation 67±1 years old (34 pts <65 y/o) 1° outcome: time to CV death. 2° outcomes similar All cause death Stroke Worsening CHF
Exceptions to Rate vs. Rhythm Studies? Symptoms, Symptoms, Symptoms Patient preference. Patient expectation. Atrial fibrillation contributing/in-setting of other process CHF especially tachycardia-mediated cardimyopathy. COPD, pneumonia. Younger age? Average age of previous studies was What is appropriate strategy in younger (<50-60) patients? Patients with difficult to control heart rates. Future studies to determine any additional benefits of ablation.
Other Driver for Determination of Strategy? Vignette #1 54 y/o male with a-fib diagnosed after presentation for mild palpitations. Initially felt no other new symptoms. Now is pre-occupied with a-fib, can’t stop thinking about it. Vignette #2 74 y/o male with new a-fib. DOE, palpitations, exertional intolerance. Patient Choice
Quick clinical caseQuick clinical case 62 y/o male with atrial fibrillation and no Sx. CHADSVASC of 0. Recent cardioversion failure x3. 1 st w/o AAD. 2 nd on 50 mg bid flecainide. 3 rd on 100 mg bid flecainide. What is next most appropriate management strategy? 1. Accepting a-fib, rate control strategy. 2. EP study and ablation for PVI. 3. Repeat trial of cardioversion on amiodarone. 4. Repeat trial of cardioversion on non-amio AAD.
Rate ControlRate Control
Beta-blockers: Metoprolol generally preferred. Don’t like atenolol in older patients with CRI Carvedilol preferred in LV dysfunction. Calcium channel blockers (diltiazem, verapamil): Should not be used with LV dysfunction. Less of an issue with sinus rate slowing. Digoxin: I do not generally use.
HR Target?HR Target? Lenient vs. Strict Rate Control. 614 patients Lenient: resting HR <110 bpm. Strict: resting HR <80 bpm, moderate exercise: <110 bpm. Primary outcome: composite of CV deaths, CHF hospitalization, stroke or SE, bleeding and life threatening arrhythmias. 2-3 year follow-up.
Lenient vs. Strict Rate Control P<0.001 for pre-specified non-inferiority margin. More patient’s to target in lenient group. 97.7% vs. 67% Fewer total visits 75 vs Similar frequency of Sx and Aes Exceptions?
Rhythm ControlRhythm Control
Cardioversion. Quick, easy. Infrequent cardioversion acceptable as sole rhythm control. Medications (Anti-arrhythmics). Numerous, can feel like “spinning” your wheels. Class IIa recommendation: “Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy.” Ablation.
2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Ablation Strategies for Atrial Fibrillation
Rationale For A-fib Ablation: PVI
What is success rate of ablation for atrial fibrillation (PVI)? 1.50% 2.65% 3.75% 4.Who knows/Need more information.
What is success rate of ablation for atrial fibrillation (PVI)? 1.50% most AADs 2.65% amiodarone 3.75% 4.Who knows/Need more information.
Ablation vs. AADsAblation vs. AADs Meta-analysis 6 studies. Prospective studies. Mainly paroxysmal/persiste nt. 693 total patients. 65% RRR of a-fib with ablation Nair et al., JCE, 2009, 20: 138.
Ablation Success/RisksAblation Success/Risks Questionnaire study (Cappato et al., Circ Arrhyth Elect, 2010, 3(1): 32. Worldwide survey (521 centers) Results: ablations (16309 patients, ) Mean f/u: 18 months (3-24 months) asymptomatic w/o AADs 2047 asymptomatic w/ AADs Conclusions: Effective in 80% of patients after 1.3 procedures/pt Effective w/o AAD in 70% Major complications: 4.5%
Atrial Fibrillation AblationAtrial Fibrillation Ablation In general, ablation has better success rates. Ongoing trials. Technology/strategies continue to evolve. Appropriate candidates for ablation: Significant symptoms to warrant rhythm control. Failure/intolerance of anti-arrhythmics. Desire to not take anti-arrhythmics.
Guidelines: 2011 ACCF/AHA/HRS Focused Update on the Management of A- fib (Update of 2006 Guidelines) Class I: Catheter ablation performed in experienced centers (>50/year) is useful in maintaining sinus rhythm in selected patient with significantly symptomatic, paroxysmal AF who have failed treatment with an AAD and have normal-mildly dilated LA, normal-mildly reduced LV function and no severe pulmonary disease.
Guidelines: 2011 ACCF/AHA/HRS Focused Update on the Management of A- fib (Update of 2006 Guidelines) Class IIa: Catheter ablation is resonable to treat symptomatic persistent AF. Class Iib: Catheter ablation may be reasonable to treat symptomatic paroxysmal AF in patients with significant left atrial dilation or with significant LV dysfunction.
Future of Rhythm ControlFuture of Rhythm Control Do results of Affirm and other rate vs. rhythm control studies apply to atrial fibrillation ablation? On-treatment analysis of Affirm. Independent studies looking at benefits of a-fib ablation. Ongoing and future trials of a-fib ablation: CABANA
Exceptions to TrialsExceptions to Trials On-treatment analysis of AFFIRM SR and warfarin use associated with lower risk of death. AADs use associated with increased mortality AADs no longer associated with mortality after adjustment for SR Corley et al., Circulation, 2004, 109:
Effects of A-fib Ablation on Risk of Stroke and Death International multicentre registry 7 countries in UK and Australia. Consecutive patients undergoing catheter ablation of AF. 1273 pts, 58±11 years Long-term outcomes compared to: Cohort with AF treated medically in Euro Heart Survey. Hypothetical cohort without AF but age and gender. Analysis after 1 st procedure regardless of success, intention-to-treat basis.
Effects of A-fib Ablation on Risk of Stroke and Death Success rates: Paroxysmal: 85% (76% off AAD). Persistent: 72% (60% off AAD). Lower rates of stroke and death in cohort compared to medical treatment. Rates of events no different compared to general population. Hunter et al., Heart, 2012; 98: 48.
Practical ManagementPractical Management
Triage: 1 st presentation.Triage: 1 st presentation. Admit/ER evaluation vs. outpatient management. Unstable patient?—think of other cause! PE CHF ACS, etc. Heart rate unacceptably high? What is cut-off for “too high”? Generally make decision based on symptoms.
Outpatient ManagementOutpatient Management Decision on OAC. Long-term management: CHADSVASC score vs. Risks of OAC. If above risk is low, plan for rhythm control in future? Routine tests: Echo, TSH, CBC, chemistry panel. Need evaluation for OSA. Are other symptoms present requiring further work-up. Rate vs. Rhythm control. I always offer a trial of rhythm control. Referral?