Atrial Fibrillation: The Ten Messages

Atrial Fibrillation: The Ten MessagesAli Alsayegh, MD, FRCPC,FACCConsultant Cardiologist, Consultant Cardiac ElectrophysiologistOneAF is relatively common and ChallengingPrevalence of Atrial Fibrillation

Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults. JAMA. 2001; 285:2370-2375Clinical Events (outcomes) affected by AF

44TwoTypes of AFClinical Types

66Pathophysiological TypesAF cause by trigger with normal left atrium (substrate). Possible cure

AF without trigger but abnormal substrate. ProgressiveThreePatient profile very well

Common coexistent conditions

European Heart Journal. ESC Guidelines99EHRA score of AF- related symptomsAF = atrial fibrillation; EHRA = European Heart Rhythm Association

1010CHADS2 score and stroke rate

1111Risk factor-based point-based scoring system - CHA2DS2-VASc

1212The HAS-BLED bleeding risk score

1313FourTreatment OptionsRate and rhythm control of AF. Mortality outcome

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators

Aliot E , and Ruskin J N Eur Heart J Suppl 2008;10:H32-H54Predictor of Mortality In AFFIRM16Predictors of mortality in the AFFIRM trial. Based on data from the AFFIRM trial (the AFFIRM Investigators20).Five Prevent Stroke Before It HappensHighly preventable (65% RRR)

SixNovel New AnticoagulantsApproved agents for the prevention of stroke in patients with AF

Antiplatelet agents used for stroke prophylaxis in patients with AF

SevenRate Control is not Bad in Many Patients

Optimal level of heart rate control

2323Rate control of atrial fibrillation

2424AV node ablation in AF patientsaClass of recommendation. bLevel of evidence.AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy; LV = left ventricular;LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.

2525

Wood M et al. Circulation 2000;101:1138-1144Quality of life and symptoms after AV junctional ablation and pacing26Graphic representation of effect sizes and 95% CIs for measures of quality of life and symptoms after AV junctional ablation and pacing. Graph format and abbreviations as in Figure 1. These normalized effect size values have no units. QOL indicates quality of life, and Sx, symptoms. P0.005 for all effect sizes (Table 4).Choice of pacemakers afterAV node ablation

2727EightRhythm control: DrugPrinciples of antiarrhythmic drugtherapy to maintain sinus rhythmTreatment is motivated by attempts to reduce AF-relatedsymptoms.Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest.Clinically successful antiarrhythmic drug therapy may reduce ratherthan eliminate recurrence of AF.If one antiarrhythmic drug fails a clinically acceptable responsemay be achieved with another agent.Drug-induced proarrhythmia or extra-cardiac side-effects arefrequent. Safety rather than efficacy considerations should primarily guidethe choice of antiarrhythmic agent.2929Chance of Staying in Sinus Rhythm

Choice of antiarrhythmic drugaccording to underlying pathology

3131Nine Rhythm control: Left Atial AblationCurrent approaches to catheter ablation

Catheter ablation is currently based on four main strategies:Isolation of the triggers and perpetuating re-entrant circuits located in the pulmonary veins;Disruption of the substrate for perpetuating rotors in the antra of the pulmonary veins;Disruption of putative dominant rotors in the left and right atria, recognized by high-frequency complex fractionated electrograms during mapping of AF. Targeted ablation of ganglionated autonomic plexi in the epicardial fat pads.

Pulmonary veins isolation

Success Rate of AF Ablation

Rhythm control more likely to succeed Recent Onset AFNo structural heart diseaseSmall LA Younger AgeReversed precipitating factor

TenNewer Therapeutic options

Blood thinner alternative: Left Atrial Occlusion Device

Investigational Antiarrhythmic Agents

Summary for AF Management from ESC Guidelines

4040Thank You