1. Current Mangement of Atrial Fibrillation: An Evidence-Based Approach
John D. Hummel, MD
Ohio State University Medical Center
Ross Heart Hospital
Columbus, Ohio

2. Learning Objectives
Understand the guidelines for anticoagulation and where there is latitude for physician decisionmaking.
Be able to discriminate between patients requiring restoration of sinus rhythm vs. rate control alone.
Be able to determine when patients should be evaluated for curative ablation.

3. Atrial Fibrillation Easily recognized.
Seems to bother healthcare workers as much as patients.
Who’s Problem? Internists cardiologists EP.

4. Projected Number of Adults With AF in the US: 1995 to 2050.
Go A, et al. JAMA. 2001;285:

5. Atrial Fibrillation: Costs to the Health Care System
ALOT!!
35% of arrhythmia hospitalizations
Average hospital stay = 5 days
Mean cost of hospitalization = $18,800
Does not include:
Costs of outpatient cardioversions
Costs of drugs/side effects/monitoring
Costs of AF-induced strokes
Estimated US cost burden 15.7 billion

6. Classification of Atrial Fibrillation ACC/AHA/ESC Guidelines
First Detected
Paroxysmal (Self-terminating)
Persistent (Not self-terminating)
Permanent
Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation.) J Am Coll Cardiol. 2001;38:

7. AHA / ACC / ECS Guidelines 2006
DIAGNOSTIC WORKUP
Minimum Evaluation
History and physical – Sx with AF, CV dz
Electrocardiogram – WPW, BBB, LVH, MI
Echocardiogram – LVH, LAE, EF, Valve Dz
Labs – TSH, Renal fxn, LFTs
Additional Testing
ETT – CAD, Exercise induced SVT / AF
Holter / Event Monitor – Confirm AF and Sxs
TEE – LA clot
EPS – SVT triggered AF
AHA / ACC / ECS Guidelines 2006

8. AF: TREATMENT OPTIONS Prevent remodeling Rate control
Maintenance of SR
Stroke prevention
Pharmacologic
Nonpharmacologic
Pharmacologic
Warfarin
Thrombin inhibitor
Aspirin
Nonpharmacologic
Removal / isolation LA appendage
Pharmacologic
Ca2+ blockers
-blockers
Digitalis
Amiodarone
Nonpharmacologic
Ablate and pace
Class IA Class IC Class III
-blocker
Catheter ablation
Surgery (MAZE)
Pacing
There are 3 strategies for the management of patients with AF: rate control, maintenance of SR, and stroke prevention. A combination of strategies may be appropriate in some patients.
Rate control is usually easier to achieve than SR maintenance, but the disadvantage is persistence of an irregular ventricular response that does not allow for symptomatic relief for many patients. Although hemodynamic function is improved with rate control, maintenance of SR frequently leads to better results. The drugs (Ca2+ blockers, -blockers, and digitalis) used to maintain ventricular response may cause very slow heart rates in some patients. These patients may require implantation of a permanent pacemaker.
Maintenance of SR has 2 proven advantages, relief of symptoms and improved hemodynamics. In addition, there is the theoretical (but not proven) possibility that maintenance of SR leads to a decrease in thromboembolic events and electrical atrial remodeling. The disadvantage of choosing maintenance of SR as a treatment option is the drug (class IA, IC, and III, -blockers) side effects, which are usually only an annoyance, but can be life-threatening in a small percentage of patients.
Nonpharmacologic approaches to maintaining SR (MAZE, pulmonary vein isolation) are important adjunctive therapies to consider for patients who are already undergoing cardiac surgery, but are rarely required as first-line therapy. Implantable atrial defibrillators are another nonpharmacologic approach, but substantial patient discomfort and a narrow indication are 2 major disadvantages. Catheter ablation is also an option, and several approaches to this therapy have been reported.
Stroke prevention is important for AF patients with a high risk for stroke. Such patients require warfarin alone or in combination with aspirin as anticoagulation therapy. The nonpharmacologic approach to stroke prevention is LA appendectomy. This can be used as adjunctive or stand-alone therapy and could markedly reduce the risk of embolic stroke and possibly avoid long-term warfarin therapy.
Prevent remodeling
ACE-I
ARB
Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.
Prystowsky EN. Management of atrial fibrillation: therapeutic options and clinical decisions. Am J Cardiol. 2000;85:3D-11D.

9. Risk Factors for Thromboembolism in AF
High-Risk Factors Recommended Therapy
Previous CVA / TIA / Embolism High-risk factor or > 2
Mitral Stenosis moderate-risk factors
Prosthetic heart valve Coumadin INR 2-3
Moderate-Risk Factors (mechanical valve INR > 2.5)
Age > 75 yrs
HTN moderate-risk factor
CHF ASA or Coumadin DM
EF < 35% No risk factors
Weaker-Risk Factors ASA mg daily
Female
CAD
Thyrotoxicosis
Age 65 – 74 yrs
AHA / ACC / ECS Guidelines 2006

10. AF THERAPY
ANTITHROMBOTIC RX
RHYTHM
CONTROL
RATE
OR ?
AND

11. AFFIRM Trial: Rate vs Rhythm Control Management Strategy Trial
Design
5-year, randomized, parallel-group study comparing rate control vs. AARx attempt at NSR
Primary endpoint: overall mortality
Patient population
4060 patients with AF and risk factors for stroke
Mean Age = 69 yo
Hx of hypertension: 70.8%
CAD: 38.2%
Enlarged LA: 64.7%
Depressed EF: 26.0%
The AFFIRM Investigators. N Engl J Med. 2002;347:

12. AFFIRM: All-Cause Mortality30
Rate
Rhythm 25 20
p=0.078 unadjusted 15
Mortality, %
p=0.068 adjusted 10 5 1 2 3 4 5
Time (years)
Rhythm N:
2033
1932
1807
1316
780
255
Rate N:
2027
1925
1825
1328
774
236
The AFFIRM Investigators. N Engl J Med. 2002;347:

13. AFFIRM: Adverse Events
Rate
Rhythm
Ischemic stroke
77 (5.5%)*
80 (7.1%)*
INR < 2.0
27 (35%)
17 (21%)
Not taking warfarin
25 (32%)
44 (55%)
* p=0.79
The AFFIRM Investigators. N Engl J Med. 2002;347:

14. AF Rate vs. Rhythm Control Trials: Implications
AFFIRM has demonstrated that rate control is an acceptable primary therapy in a selected high-risk subgroup of AF patients
Continuous anticoagulation seems warranted in all patients with risk factors for stroke
Asymptomatic recurrences

15. Atrial fibrillation Rate control – the problem:
Increased rates – more symptomatic, greater hemodynamic impact.
Persistent increased rates – tachycardia induced cardiomyopathy
Rate control – the goal:
PAF – control symptomatic tachycardia
Chronic afib – mean 24hr HR < bpm

16. Atrial fibrillation Rate control – Drug Therapy:
Digoxin – controls resting rate, OK in CHF patients .
Beta, Ca+2 blockers – controls resting and exercise rates.
Best therapy – combination of beta blocker and
digoxin.
Even in the best of circumstances pacing support is sometimes required

17. APPROACHES TO AF THERAPY
Rate control plus
anticoagulation preferred
No or lesser AF symptoms
Longer AF Hx
More SHD
Toxicity Risk
Elderly
Greater risk of
proarrhythmia
Rhythm control
preferred
Greater AF symptoms
Symptoms despite rate control
Younger age
No or lesser SHD
Rx option of class IC AAD
In anticoagulation candidates, continue anticoagulation indefinitely

18. Atrial Fibrillation
Length of time in AF prior to cardioversion
100
< 3 Months
Months
> 12 Months
Duration of AF is the best predictor of recurrent AF after cardioversion 80 60
Patients in sinus rhythm (%) 40 * 20
Initial
One month post-CV
Six months post-CV
*P = <0.02
Dittrich HC. Am J Cardiol ;63:

19. AF TREATMENT GOALS
AF is rarely life-threatening and is typically recurrent
Treatment goals in symptomatic pts
 frequency of recurrences
 duration of recurrences
 severity of recurrences
Minimize risk of tachycardia induced cardiomyopathy
Safety is primary concern

20. Rhythm Control for AF: Commonly Used Oral Antiarrhythmic Drugs
Class IA
Class IC
Class III
Quinidine
Procainamide
Disopyramide
Propafenone
Propafenone SR
Flecainide
Sotalol
Amiodarone
Dofetilide
Sodium channel blockers (Class I agents) and potassium channel blockers (Class 3 agents) have been shown to be effective for rhythm control in AF.
A number of Class 3 agents are currently under clinical investigation for use in rhythm control of AF. They include:
Azimilide
Dronedarone
Trecetilide
Procainamide, disopyramide, and amiodarone are not FDA-approved for treatment of AF.
Miller and Zipes. In: Braunwald, et al (eds). Heart Disease. 6th ed

21. AF Efficacy: Maintaining NSR > 6 Months

22. ORGAN TOXICITY Examples: Negligible: Acceptible: High:
Lupus, agranulocytosis, thrombocytopenia, optic neuritis, pulmonary fibrosis, hepatitis, etc.
Negligible:
Dofetilide, flecanide, propafenone, sotalol
Acceptible:
Azimilide, disopyramide
High:
Amiodarone, procainamide, quinidine

23. Drug-Induced Proarrhythmia - Torsades

24. Factors Which Influence Ventricular Proarrhythmia Risk
Hypokalemia, hypomagnesemia
Long QT at baseline
CHF / Decreased EF / Ventricular hypertrophy
Bradycardia
Female gender
Reduced drug metabolism or clearance
Amiodarone has lowest risk

25. Atrial fibrillation Heart disease Antiarrhythmic None IC
Vagal afib Disopyramide
HTN IC (if no sig. LVH)
CAD Sotalol
CHF/Substantial Amiodarone
LVH

26. Alternatives to Drug therapy “Non-Pharmacologic Therapy”
Coumadin – LAA closure (Watchman)
Rate Control – AVN RFA + PCMK
AARx – Adjunctive AFL RFA
AARX – Curative Afib RFA

27. WATCHMAN® LAA Filter System

28. Complete AVN ablation

29. Pacemaker Placement

30. AVN RF ablation

31. Objective Benefits of AV nodal Ablation70 55 50
mean
54 + 7
mean
34 + 5 60 45 50 40
mean
43 + 8
LVEF (%)
LVESD (mm)
mean
40 + 5 35 40 30
p < 0.001
p < 0.003 30 25 20 20
Before
After
Before
After
A Left ventricular ejection fraction (%)
B Left ventricular end systolic diameter (mm)
Rodriguez LM. Am J Cardiol ;72:

32. Complete AVN Ablation Advantages: 100% efficacy
85% symptomatic improvement
Improved EF (LV remodeling)
Eliminates need for rate control drugs
Disadvantages:
Pacemaker dependant
Good Candidates:
Tachy / Brady Syndrome
PCMK in Place – CHF with BiV device
Medication refractory / intolerant
Elderly

33. 60 F with PAF treated with Rythmol Presented with recurrent tachycardia
ECG #4
Clinical Information:
This 58-year old woman presented to an emergency department with palpitations and shortness of breath.
ECG Findings:
The ECG shows atrial flutter at a rate of 290 bpm with 2:1 AV block. Two aberrant beats are present which are probably ventricular in origin.

34. Atrial Flutter Circuit

35. Atrial Flutter Circuit

36. Atrial Flutter Ablation

37. Atrial Flutter RFA

38. Atrial Flutter Ablation
Approximately 15% of AF patients treated with an AA will develop AFL
Advantages:
95% efficacy
≈ 80% arrhythmia control if AARx continued
As primary Tx RFA more effective than AARx
Disadvantages: Invasive
Good Candidates:
Typical AFL (IVC / TV isthmus)
Primary AFL or AARx related AFL

39. Focal Origin of Atrial Fibrillation Hassaiguerre M, NEJM, 1998RA LA
94% of AF triggers from Pulmonary Veins
“90 – 95% of all AF is initiated by PV ectopy”
SVC 17 31 FO
Pulmonary Veins 6 11
IVC CS

40. * 74 yo medically refractory AF, Echo – Normal
AA Rx - Verapamil, Rythmol, Betapace, Norpace I II
III V1
RSPV
dist
prox
LIPV RA *

41. Lasso Catheter

42. Circular Mapping & Ablation Catheter in Right Superior Pulmonary Vein

43. Atrial Fibrillation Ablation Atrial Shell and Cardiac MRI

44. 45 yo F with medically refractory Highly Symptomatic PAF

45. 45 yo F with Medically Refractory PAF CT Scan / Carto Images – PA View

46. 45 yo with PAF Conversion of AF to NSR, LSPV with AF
Abl
Lasso
LSPV CS

47. (Last 200 pts complications < 1%)
Current State of Curative Catheter-Based RFA Procedural Success & Complications
Total Patients > 800 (70% PAF)
Expected 1yr
≈ 70% after first procedure
≈ 80% after second procedure
Complications ≈ 2 to 3%
Tamponade – 0.6%
Pulmonary vein stenosis – 0.6%
TIA / CVA – 0.5%
Esophageal-LA fistula - 0
Groin Bleeding / Hematoma
(Last 200 pts complications < 1%)

48. Atrial Fibrillation: Ablation vs Drug Rx.
80% success
PV stenosis
AE fistula
TIA/CVA
Drug Rx.
50% success
Proarrhythmia
End Organ Toxicity
No Free Lunch
Torsades
AE fistula
PV stenosis

49. Current State of Curative Catheter-Based RFA Who is a good candidate?
Symptomatic / Frequent AF
Limited Heart Dz
EF > 35%
LA < 5.5cm
No MS / Rheumatic Dz
Younger Patients
No LA thrombus or Hx of CVA
Medically Refractory / Intolerant
(Ablation now second line therapy)

50. Industry Estimates: AF Demographics
Approximately 26,000 AF ablation procedures (surgery + EP) were performed in 2004.
Currently, only about 1% of AF population being addressed with curative therapies.
Estimates for EP Afib RFA:
2005 = 19,000
2006 = 21,000
(1%)
Physicians estimate apporx. 30% of Afib pts are RFA candidates.

51. The Trouble With a Moving Target
Atrial Fibrillation Ablation
Evolution of the Moving Target
Esophageal Fistulas
Left Atrial
Flutters
Tamponade
TIA/CVA
Early Rumors (20 hr cases)
Left Sided Focal
WACA + Linear
Hybrid Approaches
Mid 90’s
Need for Stereotaxis,
Cryoablation, HIFU?
IVUS / Transeptal
Lasso
3D Mapping
CT integration
2006
Right Sided Linear
PV Isolation
Fractionated Egms
Back to the Right Side
PV Stenosis
Phrenic Nerve Injury
This slide shows exactly how dyssynchrony can adversely impact pump function.
The Trouble With a Moving Target

52. Atrial Fibrillation New Technology Coming Your Patients Way at Ohio State University
Stereotaxis – Magnetic Catheter Navigation
Energy Sources
High Intensity Focused Ultrasound (HIFU)
Cryoablation Balloon
Watchman – Left Atrial Appendage Closure

53. A-Fib vs. EP Labs