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Atrial Fibrillation, Causes, Treatment and Whats New Louann Bailey, MSN, CRNP. FAANP Northeast Ohio Cardiovascular Specialist.

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Presentation on theme: "Atrial Fibrillation, Causes, Treatment and Whats New Louann Bailey, MSN, CRNP. FAANP Northeast Ohio Cardiovascular Specialist."— Presentation transcript:

1 Atrial Fibrillation, Causes, Treatment and Whats New Louann Bailey, MSN, CRNP. FAANP Northeast Ohio Cardiovascular Specialist

2 Objectives At the conclusion of the lectures the participant will: – Understand and apply current research and guidelines for Atrial Fibrillation management – Be able to apply pharmacologic therapies to Atrial arrhythmia management and treatment – Be able to verbalize non pharmacologic therapies in treatment of Atrial arrhythmia AANP 2012

3 Introduction Committee for documenting the evidence based medicine on Atrial Fibrillation – American College of Cardiology (ACC) – American Heart Association (AHA) – Heart Rhythm Society (HRS) – European Society Of Cardiology (ESC) – European Heart Rhythm Society (EHRS) AANP 2012

4 Defining Atrial Fibrillation A supraventricular Tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function Depends on the properties of the AV node and conducting tissues Level of vagal and sympathetic tone Presence or absence of accessory conduction pathways J AM Coll Cardiol, 2006: 48 149-246, ACC/AHA/ESC 2006 Guidelines for the Management of Patients with A-Fib AANP 2012

5 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Electrocardiogram showing atrial fibrillation with a controlled rate of ventricular response AANP 2012

6 Related Arrhythmias A flutter – Saw-tooth pattern of regular atrial activation called flutter Flutter waves most prominent in leads II, III, and aVF Commonly 2:1 AV block Regular or irregular May display upright P waves in II, III, aVF, but downward in V 1 Heart rate is somewhere between 120-160 bpm Atrial Tachycardia AANP 2012

7 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Electrocardiogram showing typical atrial flutter with variable atrioventricular conduction AANP 2012

8 Classification of A Fib Lone Atrial Fibrillation – There is absence of cardiac or other conditions predisposing to A Fib Acute Atrial Fibrillation – AF that lasts < 48 hours in duration Paroxysmal Afib – Recurrent, transient episodes, reverting to sinus rhythm, spontaneously or with treatment – usually < 7 days, often < 24 hours. Persistent Afib – AF that is persistent despite treatment – > 7 days AANP 2012 Hht://askdrwiki.com/meiawiki/index.php?title=Classificati on_of_Atrial_Fibrillation

9 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Patterns of atrial fibrillation (AF) AANP 2012

10 Distinguishing features of Atrial arrhythmias Atrial Tachycardia – Atrial rate 100-240 Atrial Tachycardia, multifocal – Atrial rate > 100 Supraventricular tachycardia, paroxysmal – Rate > 100, P waves not easily seen Aflutter – Saw tooth pattern, flutter wave rate 240- 300 Atrial Fibrillation – P waves absent, atrial activity totally irregular and represented by fibrillatory waves – Ventricular rate 100-180 The complete Guide to ECGs, 2 nd ed.2002 AANP 2012

11 Epidemiology and Prognosis 2.2 million people in the US and 4.5 million people in Europe have Paroxysmal or persistent AF In the past 20 years, there has been a 66% increase in hospital admissions for AF Approximately 15.7 billion is spent annually in the U.S. alone AANP 2012

12 Prevalence AF is seen in 0.4%-1% of the general population Increases with age Incidence is higher in men Median age is 75 years Number of men and women are about equal Approximately 60% of the patients > 75yo are women AAs risk is about half of whites AANP 2012

13 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Estimated age-specific prevalence of atrial fibrillation (AF) based on 4 population-based surveys AANP 2012

14 Incidence Less then 0.1% per year for those < 40 To exceed 1.5% per year in women > 80 To exceed 2% per year in men > 80 The incidence of AF may be lower in HF patients treated with ACE I AANP 2012

15 Prognosis AF is associated with an increased long term risk of stroke AF is associated with an increased risk for developing HF AF is associated with all cause mortality, especially in women AF patients have double the mortality rate as compared with those in sinus rhythm AANP 2012

16 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Relative risk of stroke and mortality in patients with atrial fibrillation (AF) compared with patients without AF AANP 2012

17 Prognosis The rate of ischemic stroke among patients with nonvalvular AF avg 5% per year AF is a strong independent risk factor for mortality One in six strokes occurs in patients with AF In HF studies, the annual risk due to AF was 1.5% in persons 50-59 and 23.5% in ages 80- 89 AANP 2012

18 Pathophysiological Mechanisms AANP 2012 Atrial Pathology Anatomical substrate Electrical Remodeling Counteracting Atrial Remodeling Other factors – Inflammation – Autonomic nervous system – Changes associated with aging

19 Anatomical and Electrophysiological substrates DiseasesAnatomicalCellularElectrophysiological HTN A substrate Atrial DilatationMyolysisConduction abnormalities HF A substrate PV dilatationApoptosis, necrosis ERP dispersion CAD A substrate FibrosisChannel Expression Change Ectopic activity Valvular disease A substrate Focal AF B substrate Only with prolonged High rates Ectopic activity A Flutter B substrate Atrial dilatationCa ++ channel down regulation Short ERP AANP 2012

20 Mechanisms of Atrial Fibrillation Automatic Focus theory – May be automatic focus or micro entrant circuit, rapid local activation in the LA cannot extend into the RA in an organized way Multiple Wavelet Hypothesis – A large atrial mass with short refractory time and delayed conduction increases the number of wavelets, favoring sustained AF AANP 2012

21 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Posterior view of principal electrophysiological mechanisms of atrial fibrillation AANP 2012

22 What Structural Changes Influences Atrial Fibrillation Atrial size Left Ventricular size Structural changes to the Pulmonary Veins Pre-disposition of pre-excitation syndrome Loss of synchronous atrial mechanical activity AANP 2012

23 Etiologies and Factors Predisposing to A Fib Electrophysiological abnormalities – Enhanced automaticity (focal AF) – Conduction abnormality (re-entry) Atrial pressure elevation – Mitral or tricuspid valve disease – Myocardial disease (systolic or diastolic disease) – Semi lunar Valvular abnormalities (causing ventricular hypertrophy – Systemic or pulmonary HTN (pulmonary Hypertrophy – Intracardiac tumors or thrombi AANP 2012

24 Etiologies and Factors Predisposing to A Fib Atrial Ischemia – CAD Drugs – Alcohol – Caffeine Endocrine – Hyperthyroidism – Pheochromocytoma Inflammatory or infiltrative disease – Pericarditis – Amyloidosis – Myocarditis – Age-induced atrial fibrotic changes AANP 2012

25 Etiologies and Factors Predisposing to A Fib Changes in autonomic tone – parasympathetic activity – sympathetic activity Primary or metastatic diseases in or adjacent to the atrial wall Congenital heart disease Postoperative – Cardiac, pulmonary, esophageal Neurogenic – SAH – Nonhemorrhagic, major stroke Idiopathic (lone AF) Familial AF AANP 2012

26 Why is it a concern? There are myocardial and hemodynamic consequences of Atrial Fib The risk of Thromboembolism is very real The risk of Stroke is very real The risk of catastrophic debilitation is very real The risk of increased morbidity and mortality is very real AANP 2012

27 Pathology of Thrombus Formation Thrombotic material associated with AF most frequently is due turbulent flow in LAA This is not seen using transthoracic echo For AF that is > 48 hours long, risk increases Virchow's triad of stasis applies – Venous stasis – Endothelial dysfunction – Hypercoagulable state AANP 2012

28 Other Interesting Facts During conversion of AF to SR, decreased velocities of flow are noted in LAA This increases risk for thromboembolic events due to stunning of the Atria Atrial stunning occurs immediately after Cardioversion and may last up till 3-4 days post Cardioversion 80% of thromboembolic strokes occur 3-10 days after Cardioversion AANP 2012

29 Other Interesting Facts HF, either diastolic or systolic, increases risk for stroke Strong association of stroke with AF and HTN Often see elevated C-reactive protein (CRP) in these patients with increased risk for stroke Pathophysiology of thromboembolism in patients with AF is uncertain and poorly defined AANP 2012

30 Other Associated Causes and Conditions that Influence AF Catecholamine surges AF without associated HD – 20-25% of AF in young adults who present Medical conditions associated with AF – Obesity and and LA dilatation AF with associated HD – Valvular (Mitral), HF, CAD, HTN, LVH Familial (Genetic) AF – Poorly understood, ongoing research AANP 2012

31 Impact on Quality of Life Can be very life limiting Worry when it will reoccur Lifelong toxic meds Bad consequences for non compliance Potential bad consequences for compliance No good substitutes for treatment Best to prevent and treat underlying cause AANP 2012

32 Clinical Evaluation Diagnosis is based on History and clinical examination and confirmed ECG Determine cause Defining associated cardiac and extracardiac factors pertinent to the etiology, tolerability and history of prior management WU and therapy initiation can usually be done in one outpatient encounter AANP 2012

33 Clinical Evaluation History and physical Exam – Presence and nature of symptoms associated with AF – Clinical type of AF – Onset of the first symptomatic attack or date of discovery – Frequency, duration, precipitating factors, modes to terminate – Response to any pharmacological agents that have been tried – Presence of any underlying heart disease or other reversible conditions AANP 2012

34 Clinical Evaluation Electrocardiogram, to identify – Rhythm – LV hypertrophy – P-wave duration and morphology or fibrilliatory waves – Pre-excitation – BBB – Prior MI – Other atrial arrhythmias – Measure R-R, QRS, QT intervals AANP 2012

35 Clinical evaluation Transthoracic echocardiogram – LA and RA size – LV size and function – Peak RV pressure (pulmonary HTN) – LV hypertrophy – LA thrombus (low sensitivity) – Pericardial disease AANP 2012

36 Clinical Evaluation Blood tests – Thyroid – Renal – Hepatic function – CBC – BNP if appropriate – CRP AANP 2012

37 Clinical Evaluation Six minute walk test – Assess for rate response Exercise Testing – To reproduce exercise induced AF – Evaluate for ischemia Holter monitoring or event recording – If type of arrhythmia is in question Transesophageal echocardiography – To ID LA thrombosis, guide DCC AANP 2012

38 Clinical Evaluation Electrophysiological study – To clarify the mechanism of wide QRS complex tachycardia – To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia CXR – Lung parenchyma, Pulmonary vasculature, cardiac size AANP 2012

39 Management Primary goals are to meet 3 objectives – Rate control – Prevention of thromboembolism – Correction of the rhythm disturbance AANP 2012

40 Management Considerations Type and duration of AF Severity an type of symptoms Associated CV disease Patient age Associated medical conditions Short-term and long-term treatment goals Pharmacological and nonpharmacological therapeutic options AANP 2012

41 Pharmacological and Nonpharmacological Therapeutic Options Drugs and ablation are effective for both rate control and rhythm control Surgery, Maze Procedure may also be an option ablate and pace strategy may be an option AANP 2012

42 Studies and Trials that support therapy Affirm Trial – Atrial Fibrillation Follow-Up Investigation of Rhythm Management RACE – Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation STAF – Strategies of Treatment of Atrial Fibrillation AANP 2012

43 Studies that support therapy HOT CAFE – How to Treat Chronic Atrial Fibrillation PIAF – Pharmacological Intervention I Atrial Fibrillation AANP 2012

44 Affirm Trial (2002) Over 4000 patients Mean age 69.7 yrs of age F/U: 3.5 yrs Inclusion criteria: PAF, Persistent AF, 65 yrs or older, or risk of stroke or death Primary endpoint: All- cause mortality % Rate control: 25.9% % Rhythm control 26.7% P value: 0.8 AANP 2012

45 IV and PO Pharmacological Agents for Rate control Acute Setting – Beta blockers Esmolol, Metoprolol, Propanolol – Nondihydropyridine Calcium channel blockers Diltiazem, Verapamil – Amiodarone (heart rate control with accessory pathway) – Digoxin (heart rate control in pts with HF without accessory pathways) AANP 2012

46 Non – Acute and Chronic Maintenance DrugClass /LOE Loading DoseOnsetMaintenance Dose Major SE MetoprololI/CMain Dose4-6 hrs25-100mg BID BP, HB, HR, asthma, HF PropanololI/CMain Dose60-90 min 80-240mg divided BP, HB, HR, asthma, HF DiltiazemI/CMain Dose2-4 hrs120-360mg divided BP, HB, HF VerapamilI/CMain Dose1-2 hrs 120-360mg divided BP, HB, HF, digoxin interaction DigoxinI/C0.5mg2 days0.125- 0.375mg daily Digitalis toxicity, HB, HR AmiodaroneIIb/C800mg daily for 1 wk then 600mg daily for 1 wk 400mg daily for 4-6 wks 1-3 wks200mg daily BP, HB, pulm, thyroid, lung toxicity, Corneal deposits, optic neuropathy, warfarin interaction, SB AANP 2012

47 Preventing Thromboembolism Who is at Risk? Risk FactorsRelative Risk Previous Stroke or TIA2.5 DM1.7 H/O HTN1.6 HF1.4 Advanced Age1.4 AANP 2012

48 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Stroke rates in relation to age among patients in untreated control groups of randomized trials of antithrombotic therapy AANP 2012

49 Using the CHADS 2 Index CHADS 2 Risk CriteriaScore Prior Stroke or TIA2 Age > 75y1 HTN1 DM all types1 HF1 AANP 2012

50 Tools Available for Predicting Bleeding Risks Two tools available for predicting bleeding risk HEMORR 2 HAGES HAS-BLED Pros/Cons Factors identified from registries or research data Yet based on warfarin only Recommendations Use info to identify those at high risk w/warfarin Stay tuned for newer predictive tools AANP 2012

51 Factors Associated w/Bleeding Risks HEMORR 2 HAGES Prior bleed (greatest risk) Liver or kidney disease Stroke Older age (> 75 years) Uncontrolled HTN Ethanol abuse Malignancy Reduced plt count/function Anemia Genetic factors Excessive fall risk HAS-BLED score Bleeding hx or predisposition Abnormal kidney/liver function Stroke Elderly (> 65 yrs) Hypertension Drugs/alcohol concomitantly Labile INR *Identified from registries/surveys using warfarin. AANP 2012

52 Antithrombotic Therapy for Patients with AF Risk CategoryRecommended Therapy No Risk factorsAspirin 81 mg to 325 mg daily One moderate risk factorASA 81 mg to 325 mg or warfarin (INR 2.0- 3.0) Any High Risk or more than 1 moderate- risk factor Warfarin (INR 2.0-3.0) AANP 2012

53 The CHADS 2 Score: Stroke Risk In Atrial Fibrillation ConditionPoints CCongestive heart failure1 HHypertension (or treated HTN)1 AAge > 75 years1 DDiabetes1 SPrior Stroke or TIA2 ScoreStroke RiskTherapy 0-1Low (< 3 %/ year)ASA 1-2Moderate ( 3-4%/yr) VKA or alternatives 3-5High ( 6-12%/yr)VKA or alternatives 6Very High ( 18%/yr) VKA or alternatives AANP 2012 See slide 60 for alternatives to VKA

54 Antithrombotic Therapy for Patients with AF Less validated or weaker Risk Factors Moderate Risk FactorsHigh Risk Factors Female genderAge > to 75Previous stroke, TIA, or embolism Age 65-74HTNMitral Stenosis CADHFProsthetic Heart Valve ThyrotoxicosisLV EF 35% or less DM AANP 2012

55 Risk Based Approach to Antithrombotic Therapy Patient FeaturesAntithrombotic TherapyClass of Recommendation Age < 60, no HD (lone AF)ASA 81-325 mg or no therapy I Age < 60, HD but no risk factors ASA 81 -325mg I Age 60-74, no risk factorsASA 81-325 mg I Age 65-74, with DM or CADOAC INR 2-3 I Age 75 or >, WomenOAC INR 2-3 I Age 75 or > Men, no risk factors OAC INR 2-3 or ASA 81-325mg I Age 65 or > with HFOAC INR 2-3 I LV EF < 35% + HTNOAC INR 2-3 I RHD (MS)OAC INR 2-3 I Prior ThromboembolismOAC INR 2-3 or higher I Prosthetic Heart ValveOAC INR 2-3 or higher I Persistent Atrial Thrombus on TEE OAC INR 2-3 of higher IIa AANP 2012

56 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Adjusted odds ratios for ischemic stroke and intracranial bleeding in relation to intensity of anticoagulation AANP 2012

57 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Effects on all stroke (ischemic and hemorrhagic) of therapies for patients with atrial fibrillation: warfarin compared with aspirin and aspirin compared with placebo AANP 2012

58 ACTIVE A ASA +/- Clopidogrel + vs. in Atrial Fibrillation (AF) AANP 2012 AF Patient DescriptionTreatment Options Moderate high risk for stroke + No contraindication to VKA VKA e.g. warfarin (target INR 2-3) unless contraindicated* (demonstrates max stroke prevention with an acceptable major bleed risk: esp. if CHADS 2 > 2, > 85 yr of age no bleed hx, or an ischemic stroke hx 1 ) Moderate high risk for stroke + cannot/will not tolerate VKA OR high-quality anticoag not achieved with VKA OR low risk for stroke ASA monotherapy 75mg daily + ASA 75-100mg daily Or Clopidogrel 75mg daily + ASA 75-100mg daily Choice depends on overall bleed risk & cost considerations: ASA + clopidogrel is similar to that with warfarin; therefore those who are not suitable for warfarin due to bleed risk, may also not be suitable for ASA + clopidogrel. Thus ASA + clopidogrel option really only suitable for patients who are not candidates for warfarin due to factors other than high risk of bleeding e.g. purple toe syndrome, lack of access to lab for required INR tests, likely not to be adherent to therapy/INR testing requirements, etc. High risk of bleed &low moderate stroke ris k ASA (75-100mg daily) 1 singer De Chang Y, Fang MC, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 2009: 151: 297-305 (VKA), Vitamin K antagonist

59 Research Trials Active A – In patients with atrial fibrillation at low-moderate risk for stroke who are not suitable for warfarin therapy, the combination of ASA+ clopidogrel is associated with a decrease in vascular event risk that is equal to the increase in risk of major bleeding – Drug cost per patient per year: ASA + clopidogrel = $1,260; ASA = $95 – Assess risk of bleed vs. any potential benefit for individual patient – If patient is on clopidogrel + a PPI, reassess need for clopidogrel &/or need for a PPI Active W – Warfarin is superior to clopidogrel + ASA for prevention of vascular events in patient with AF and at least 1 stroke risk factors especially in those already taking VKA therapy AANP 2012

60 RE-LY – Dabigatran 75-150 mg cap bid an alternative to warfarin. At the lower dose, is was as effective as warfarin with less bleeding; at the higher dose it was more effective than warfarin but with similar bleeding rates. Alter dose for GFR ROCKET AF – Rivaroxaban 15-20 mg daily, Direct Factor Xa inhibitor: evaluated and approved once a day dosing AANP 2012 Research Trials Treatment Non-Valvular Afib A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

61 Research Trials Treatment Non-Valvular Afib AVERROES ARISTOTLE – Apixaban 5 mg twice daily or 2.5 mg twice daily (age > 80, wt 1.5 mg/dl) Primary outcome: Stroke or systemic embolism Stopped early After one year Apixaban reduced stroke by half as compared to ASA Decrease in ischemic and hemorrhagic stroke Reduction in myocardial infarction and hospitalization Reduction in death Was an increase bleeding but not significant AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

62 Research Trials Treatment Non-Valvular Afib Engage AF-TIMI 48 – Looking at using Edoxaban Twice a day dosing was associated with increase in bleeding vs. Warfarin Once daily dosing was associated with similar or lower rates of bleeding of warfarin AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

63 New Anticoagulants Direct Thrombin Inhibitors – Dabigatran Factor Xa Inhibitors – Rivaroxaban – Apixaban – Edoxaban AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

64 Comparison of features of New Anticoagulants with those of Warfarin FeaturesWarfarinNew Agents OnsetSlowRapid DosingVariableFixed Food EffectYesNo MonitoringYesNo Half-lifeLongShort AntidoteYesNo AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

65 New Oral Anticoagulants AdvantageClinical Implications Rapid OnsetNo need for bridging PredictableNo need for routine monitoring Specific Coagulation enzyme targetLow risk for off target adverse effects Low Potential for food interactionNo dietary precautions Low potential for drug interactionsFew drug interactions AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

66 Disadvantages vs. Warfarin FeaturesWarfarinNew Agents FrequencyOnce DailyTwice daily MonitoringINRUncertain ClearanceNon-renalRenal 25%-80% AntidoteVitamin K, FFP, PCCNil FamiliarityExtensiveMinimal AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

67 Indirect Comparisons vs Warfarin FeatureDabigatran (110 mg) Dabigatran (150 mg) Rivaroxaban EfficacyNon-inferiorSuperiorNon-inferior Ischemic StrokeSimilarReducedSimilar Intracranial hemorrhage ReducesReduced Major bleedingReducedSimilar MIIncreased Similar DyspepsiaYes No DosingTwice Daily Once daily Time in therapeutic range 67% (median) 58%(Median) AANP 2012 A new Era in the management of Atrial Fibrillation: An update on OAC, 2011, Heart.Org

68 Interrupting Therapies For Surgical or diagnostic procedures – Elective, off therapy for 5-7 days – For Prosthetic valves, bridge with LMWH or unfractionated heparin Dental extractions – May not have to stop GI bleeds – Till cleared by GI, look at alternative Intra cranial bleeds – Stop indefinitely AANP 2012

69 Non Pharmacological Approaches to Prevention of Thromboembolism Obliteration of the LAA – Surgical removal – Intravascular catheters – Transpericaridal approaches AANP 2012

70 PROTECT AF Clinical Trial Design Prospective, randomized study of WATCHMAN LAA Device vs. Long-term Warfarin Therapy 2:1 allocation ratio device to control 800 Patients enrolled from Feb 2005 to Jun 2008 – Device Group (463) – Control Group (244) – Roll-in Group (93) 59 Enrolling Centers (U.S. & Europe) Follow-up Requirements – TEE follow-up at 45 days, 6 months and 1 year – Clinical follow-up biannually up to 5 years – Regular INR monitoring while taking warfarin Enrollment continues in Continued Access Registry AANP 2012

71 Watchman LAA Closure Technology The WATCHMAN LAA Closure Technology is designed to prevent embolization of thrombi that may form in the LAA. The WATCHMAN ® Left Atrial Appendage Closure Technology is intended as an alternative to warfarin therapy for patients with non-valvular atrial fibrillation. AANP 2012

72 Left Atrial Appendage Device Watchman Device Placed in LAA AANP 2012

73 WATCHMAN LAA Closure Device in situ AANP 2012

74 PROTEC AF Conclusion The WATCHMAN LAA Technology offers a safe and effective alternative to warfarin in patients with non-valvular atrial fibrillation at risk for stroke and who are eligible for warfarin therapy AANP 2012

75 Cardioversion of AF Performed electively or urgently By means of drug or electrical shock Pharmacological Cardioversion – Most effective if AF has been less than 7 days – First time documented Often will spontaneously convert within 24-48 hrs AANP 2012

76 Drugs used for DCC within 7 days of discovery Agents with proven Efficacy DrugRouteClassLOE Dofetilideoral I A Flecainideoral/IV I A IbutilideIV I A PropafenoneOral/IV I A AmiodaroneOral/IV IIa A Agents Less Effective/Less studied DrugRouteClassLOE DisopyramideIV IIb B ProcainamideIV IIb B Quinidineoral IIb B AANP 2012

77 Drugs used > 7 days Agents with proven efficacy DrugRouteClassLOE Dofetilideoral I A AmiodaroneOral/IV IIa A IbutilideIV IIa A Agents less effective/less studied DrugRouteClassLOE DiopyramideIV IIb B Flecanideoral IIb B ProcainamideOral/IV IIb C PropafenoneOral/IV IIb B Quinidineoral IIb B AANP 2012

78 Proven Drugs for Pharmacological Cardioversion DrugRouteDosagePotential adverse effects AmiodaroneOral IV/oral Inpatient: 1.2 to 1.8 g per day in divided doses until 10 g, then 200- 400mg per day or 30mg/kg as single dose 5-7 mg/kg over 30-60 min then 1.2- 1.8 g per day continuous IV or in divided doses until 10 g, then 200- 400mg daily Hypotension Bradycardia QT prolongation Torsades GI upset Constipation DofetlideoralCreat Clear > 60ml/min 500mcq bid 40-60ml/min 250mcq bid 20-40ml/min 125mcq bid < 20ml/min contraindicated QT prolongation Torsades Adjust dose for RF, body size and age FlecainideOral IV 200-300 mg 1.5 to 3.0 mg/kg over 10-20 min Hypotension A flutter w RVR IbutilideIV1mg over 10 min may repeatQT prolongation Torsades Propafenoneoral600mgHypotension A flutter AANP 2012

79 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Pharmacological management of patients with newly discovered atrial fibrillation (AF AANP 2012

80 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Pharmacological management of patients with recurrent paroxysmal atrial fibrillation (AF) AANP 2012

81 Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply. Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246 Pharmacological management of patients with recurrent persistent or permanent atrial fibrillation (AF) AANP 2012

82 Vaughan Williams Classification of Antiarrhythmic Drugs Type IA – Dispyramide – Procainamide – Quinidine Type IB – Lidocaine – Mexiletine Type IC – Flecainide – Propanfenone Type II – Beta blockers Type III – Amiodarone – Bretylium – Dofetilide – Ibutilide – Sotalol Type IV – Nondihydropyridine calcium antagonists AANP 2012

83 Other Antiarrhythmic without Iodine SE Dronedarone Dose 400 mg twice daily, PO Cost $9.00/day, $4.50/pill Achieve steady state in 4-8 days Elimination ½ life is 13-19 hours Metabolized via CYP 3A Several studies looking at reduced M&M ATHENA, EUROIDIS/ADONIS, ANDROMEDA AANP 2012

84 Dronedarone Indications for use – Antiarrhythmic drug indicated to reduce the risk of CV hospitalization in patients with paroxysmal or persistent atrial fibrillation (AF) or atrial flutter (AFL), with a recent episode of AF/AFL and associated CV risk factors (i.e., age > 70, HTN, DM, prior CVA, LAA diameter > 50mm or LVEF < 40%, who are in sinus rhythm or will be cardioverted) AANP 2012

85 Dronedarone Contraindications – In patients with NYHA Class IV failure – In patients with recent decompensated NYHA Class II-III HF, requiring hospitalization or referral to a specialist for HF or HF clinic – Second and third degree heart block or SSS (exception is if they have PPM) – Concomitant use of Strong CYP3A inhibitor AANP 2012

86 Dronedarone Contraindications continued – Concomitant use of drugs or herbals that may prolong QT interval – QTc Bazett interval > 500 ms – Severe hepatic impairment – Pregnancy – Nursing mothers AANP 2012

87 Dronedarone Warnings and Precautions – If HF develops or worsens, drug should be suspended – Maintain normal range levels of potassium and magnesium – Stop drug if QTc is > 500 ms – Check renal function within 1 week of starting – Teratogen: advise women of childbearing age to use contraception while on drug AANP 2012

88 Dronedarone in Permanent Afib Recent findings found to affect Hepatic function www.fda.gov/Drugs/drugssafety/ucm240011.htm Increased risk of first Coprimary outcomes (stroke, MI, Systemic Embolism, or death from CV Causes) Increased risk of second Coprimary Outcomes (Unplanned Hospitalizations for CV causes or Death) AANP 2012 NEJM10.1056.Nov 14, 2011

89 Risk of First Copriamry Outcome AANP 2012 NEJM10.1056.Nov 14, 2011

90 Risk of Second Coprimary Outcome AANP 2012 NEJM10.1056.Nov 14, 2011

91 Typical Doses of Drugs used to Maintain Sinus Rhythm DrugDaily dosagePotential Adverse Effects Amiodarone100 – 400 mgPhotosensitivity, Pulm Toxicity, polyneuropathy, GI upset, bradycardia, Torsades de pointes (rare), Hepatic toxicity, thyroid dysfunction, eye complications Disopyramide400 – 750 mgTorsades de pointes, HF, glaucoma, urinary retention, dry mouth Dofetilide500 – 1000 mcqTorsades de pointes Flecainide200 – 300 mgVT, HF conversion to AFL with RVR Profafenone450 – 900 mgVT, HF conversion to AFL with RVR Sotalol160 – 320 mgTorsades de pointes, HF, bradycardia, exacerbation of COPD or bronchospastic lung disease AANP 2012

92 Types of Proarrhythmia During Treatment Ventricular proarrhythmia – Torsades de pointes (VW IA and III drugs) – Sustained monomorphic VT (VW type IC) – Sustained polymorphic VT/VF without long QT (VW types IA, IC) Atrial proarrhythmia – Provocation of Recurrence (Type IA, IC, and III) – Conversion of AF to flutter (Type IC) – Increase of defibrillation threshold (Type IC) AANP 2012

93 Types of Proarrhythmia During Treatment Abnormalities of conduction or impulse formation – Acceleration of ventricular rate during AF (Type IA and IC) – Accelerated conduction over accessory pathway (digoxin, IV Verapamil, or Diltiazem) – Sinus node Dysfunction, AV blk (almost all drugs) AANP 2012

94 Factors predisposing to Drug Induced Ventricular Proarrhythmia VW types IA and III agents – Long QT interval (QTc > than or = to 460ms – Long QT interval syndrome – Structural HD, substantial LVH – Hypokalemia/Hypomagnesemia – Female gender – Bradycardia Maybe drug induced, sinus node disease, etc Go www.torsades.org AANP 2012

95 Factors predisposing to Drug Induced Ventricular Proarrhythmia VW type IC agents – Wide QRS duration > 120 ms – Concomitant VT – Structural HD – Depressed LV function – RVR During exercise During rapid AV conduction Rapid dose increase High dose accumulation Adding Negative Inotropic drugs Excessive QRS widening (more than 150%) AANP 2012

96 Drugs that help with DCC EfficacyEnhance DCC and Prevent IRAF ClassLOESuppress SRAF KnownAmiodarone IIA BAll drugs in Class I except ibutilide plus Beta blockers Flecanide Ibutilide Propafenone Quinidine Sotalol AANP 2012

97 Drugs uncertain if help with Cardioversion EfficacyEnhance Conversion by DCC and prevent IRAF ClassLOESuppress SRAF and Maintenance therapy Uncertain/unk nown Beta blockers IIb CDiltiazem Dofetilide DisopyramideVerapamil Dofetilide Procainamide Verapamil AANP 2012

98 Recommendations for Thromboembolism Prevention AF less then 48 hrs not needed, assess risk, underlying cause AF 48 hrs or longer, non emergent, OAC with INR 2-3 for at least 3 wks or alternate OAC AF 48 hrs or longer, urgent/emergent, heparin should be given unless contraindicated, PTT should be 1.5-2 times normal AF less than 48 hrs associated with hemodynamic instability; DCC immediately AANP 2012

99 Recommendations for Thromboembolism Prevention Alternative to anticoagulation prior to DCC, perform TEE to evaluate for LAA thrombus, then give unfractionated heparin For those with positive TEE for LAA thrombus, OAC with therapeutic INR for 3-4 wks prior to DCC and 3-4 wks after AANP 2012

100 Maintenance of Sinus Rhythm Look for underlying cause Pharmacological therapy can be useful to maintain SR and prevent Tachycardia induced CM Infrequent, well tolerated recurrence of AF is reasonable as a successful outcome of drug therapy Patients without structural HD can have meds started as an outpatient AANP 2012

101 Maintenance of Sinus Rhythm Catheter ablation may be an alternative for patients with little or no LAE This is a procedure that requires a skilled electrophysiologist and staff Currently this is done via, percutaneously and/or also using Robotics AANP 2012

102 Robotic Ablation with Niobe Stereo taxis AANP 2012

103 ICE: LA Appendage LAA LA IAS AANP 2012

104 LIPV LSPV LA AANP 2012

105 Transseptal TSP Needle RA LA AANP 2012

106 Transseptal: Needle advancement AANP 2012

107 PV Angio: Identification of ostium AANP 2012

108 ICE Imaging of the Esophagus AANP 2012

109 Char formation

110 Pericardial Effusion Cardiac Tamponade AANP 2012

111 PV Antrum Isolation: Catheter Ablation ICE+Circular Mapping Catheter AANP 2012

112 RECURRENT PAROXYSMAL AF RECURRENT PAROXYSMAL AF Minimal or no symptoms Anticoagulation and rate control as needed No drug for prevention of AF No drug for prevention of AF Disabling symptoms in AF Anticoagulation and rate control as needed Antiarrhythmic drug therapy AF ablation if Antiarrythmic drug treatment fails Treatment Algorithms for AF AANP 2012 Fuster Vet et al. JACC. 2006, 48:e 149-246

113 Consider ablation for severely symptomatic recurrent AF after failure of greater than or equal to 1 antiarrhythmic drug plus rate control Consider ablation for severely symptomatic recurrent AF after failure of greater than or equal to 1 antiarrhythmic drug plus rate control Minimal or no symptoms Anticoagulation and rate control as needed Anticoagulation and rate control as needed Disabling symptoms in AF Anticoagulation and rate control Antiarrhythmic drug therapy Electrical cardioversion as needed Continue anticoagulation as needed and therapy to maintain sinus rhythm RECURRENT PERSISTENT AF RECURRENT PERSISTENT AF Treatment Algorithms for AF (cont) AANP 2012 Fuster Vet et al. JACC. 2006, 48:e 149-246

114 PERMANENT AF Anticoagulation and rate control as needed Treatment Algorithms for AF (cont) AANP 2012 Fuster Vet et al. JACC. 2006, 48:e 149-246

115 MAINTENANCE OF SINUS RHYTHM No (or minimal) heart disease Flecainide Propafenone Sotalol Flecainide Propafenone Sotalol Amiodarone Dofetilide Amiodarone Dofetilide Catheter ablation Hypertension Substantial LVH No Yes Flecainide Propafenone Sotalol Amiodarone Amiodarone Dofetilide Catheter ablation Coronary artery disease Dofetilide Sotalol Amiodarone Catheter ablation Amiodarone Dofetilide Catheter ablation Heart failure Antiarrhythmic drug therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation AANP 2012 Fuster, V. et al. J Am Coll Cardiol 2006;48:e149-e246


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