All You Need to Know About Atrial Fibrillation

Jonathan S. Steinberg, MDDirector, SMG Arrhythmia Center

Director, Cardiac Clinical Trials and EducationProfessor of Medicine (adj)

University of Rochester School of Medicine

973-436-4155 www.arrhythmia.org

Atrial Fibrillation Demographics

Feinberg WM, Arch Intern Med 1995

U.S. population

Population withatrial fibrillation

Age, yr

<5 5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

>95

U.S. populationx 1000

Population with AFx 1000

30,000

20,000

10,000

0

500

400

300

200

100

0

Consequences of AF• Symptoms

None Palpitations Weakness and shortness of breath

• Stroke Based on age and other cardiovascular

risk factors• Heart Failure

Atrial Fibrillation and Stroke

• Risk: 5 - 8% per year in high-risk patients.

• Anticoagulant therapy is clearly indicated and beneficial in rheumatic atrial fibrillation.

• In non-rheumatic atrial fibrillation, major randomized trials have provided useful guidelines for identifying and treating patients at risk.

Anticoagulant Therapy in AF

Benefit

Harm

7

Risk Factors for Stroke• Congestive heart failure• Hypertension• Age ≥ 65 years• Diabetes mellitus• Prior stroke/TIA• Vascular disease (e.g. PAD, heart attack)• Female genderCHA2DS2-VASc

TEE LAA thrombus

Stroke in Atrial Fibrillation

Treatment Options• Anticoagulants

Warfarin (Coumadin) Non Vitamin K oral anticoagulants (NOACs)

• Pradaxa• Xarelto• Eliquis• Savaysa

Not aspirin• Control of symptoms

Medications to slow heart rate Medications to prevent recurrences (antiarrhythmics) Catheter ablation to eliminate AF

Treatment Options• Anticoagulants

Warfarin (Coumadin) Non Vitamin K oral anticoagulants (NOACs)

• Pradaxa• Xarelto• Eliquis• Savaysa

Not aspirin• Control of symptoms

Medications to slow heart rate Medications to prevent recurrences (antiarrhythmics) Catheter ablation to eliminate AF

Left Atrial Appendage Closure

Watchman

Treatment Options• Anticoagulants

Warfarin (Coumadin) Non Vitamin K oral anticoagulants (NOACs)

• Pradaxa• Xarelto• Eliquis• Savaysa

Not aspirin• Control of symptoms

Medications to slow heart rate Medications to prevent recurrences (antiarrhythmics) Catheter ablation to eliminate AF

Medical Therapy• Rate Control

• Calcium channel blockers (e.g. diltiazem)• Beta blockers (e.g. metoprolol, bisoprolol, etc)

• Rhythm Control• Propafenone• Flecainide• Amiodarone• Sotalol• Dronedarone• Dofetilide Only about 50% of patients respond

Pulmonary Vein Isolation

Cryoballoon

RF Ablation Catheter

MappingCatheter

Courtesy of Medtronic, Inc

Future Therapies?

• Nervous system fluctuations play an important role in AF occurrence

• Two promising and innovative approaches Renal artery denervation Botulinum toxin injection

Pokushalov, Steinberg, et al; JACC 2012;Pokushalov, Steinberg, et al; Circ AE 2015

Questions?