Challenges and Controversies in Atrial Fibrillation

Challenges and Controversies in Atrial Fibrillation

Marc J. Girsky, M.DMarc J. Girsky, M.D

Director Electrophysiology ServicesDirector Electrophysiology Services

Harbor-UCLA Medical CenterHarbor-UCLA Medical Center

Presenter Disclosure InformationPresenter Disclosure InformationPresenter Disclosure InformationPresenter Disclosure Information

Marc Girsky MD Marc Girsky MD St. Jude Medical Corporation – Research projectsSt. Jude Medical Corporation – Research projects

Atrial FibrillationOne Patient’s Odyssey

Atrial FibrillationOne Patient’s Odyssey

76 y/o male with Htn, Paroxysmal Afib76 y/o male with Htn, Paroxysmal Afib 2/2006 – 12/2006 – 1stst visit visit 2005 - 2 Cardioversions, Amiodarone – 2005 - 2 Cardioversions, Amiodarone –

Recurrent Afib, Increased LFT’sRecurrent Afib, Increased LFT’s 3/2006 – 13/2006 – 1stst Cath ablation – Flecainide 50 BID, Cath ablation – Flecainide 50 BID,

increased to 100 mg BIDincreased to 100 mg BID 1/2007 – Syncope, Amaurosis fugax, start 1/2007 – Syncope, Amaurosis fugax, start

Dofetilide, resume warfarinDofetilide, resume warfarin

One Patient’s OdysseyOne Patient’s Odyssey

3/2007 – 23/2007 – 2ndnd RFA, continue Dofetilide RFA, continue Dofetilide 12/2007 – Recurrent Afib Q8 days12/2007 – Recurrent Afib Q8 days 7/2008 – 37/2008 – 3rdrd RFA, continue Dofetilide RFA, continue Dofetilide 9/2008 – Hematuria, INR – 69/2008 – Hematuria, INR – 6 10/2009 – D/C Dofetilide, start Dronedarone10/2009 – D/C Dofetilide, start Dronedarone 11/2009 – Cerebellar infarct, resume warfarin11/2009 – Cerebellar infarct, resume warfarin 12/2010 – D/C Warfarin, initiate Pradaxa12/2010 – D/C Warfarin, initiate Pradaxa 3/2011 – Recurrent AFib3/2011 – Recurrent AFib

CP1206742-3

Underlying Pathogenesis of Atrial Fibrillation

Underlying Pathogenesis of Atrial Fibrillation

AF/disease progressionAF/disease progression

Paroxysmal

Permanent

Persistent

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imp

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Initiation substrate

Trigger

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20

40

60

80

100

ACC/AHA/ESC guidelines prepared over two years: 12 committee ACC/AHA/ESC guidelines prepared over two years: 12 committee members, 4 European, 4 North American electrophysiologists. members, 4 European, 4 North American electrophysiologists. Updated 2006Updated 2006

Exhaustive review process based on published literature: evidence-Exhaustive review process based on published literature: evidence-based recommendations and derived from published data. based recommendations and derived from published data.

Strong emphasis on randomized trials: little tolerance for “experience” Strong emphasis on randomized trials: little tolerance for “experience” or anecdotal dataor anecdotal data

ACC/AHA/ESC Guidelines for the

Management of Patients With Atrial

Fibrillation

ACC/AHA/ESC Guidelines for the

Management of Patients With Atrial

Fibrillation

Atrial Fibrillation Management Updates 2006 - Present

Atrial Fibrillation Management Updates 2006 - Present

2011 ACCF/AHA/HRS Focused Update2011 ACCF/AHA/HRS Focused Update 2010 ESC Atrial Fibrillation Guidelines2010 ESC Atrial Fibrillation Guidelines 2010 CCS Atrial Fibrillation Guidelines2010 CCS Atrial Fibrillation Guidelines

AFib Management GuidelinesNew Concepts – 2006 - Present AFib Management GuidelinesNew Concepts – 2006 - Present

Implications of Rate vs Rhythm control studies for Implications of Rate vs Rhythm control studies for clinical practiceclinical practice

Optimal anticoagulant therapyOptimal anticoagulant therapy Recommendations for catheter based therapiesRecommendations for catheter based therapies Introduce the role of angiotensin inhibition in Introduce the role of angiotensin inhibition in

reducing the occurrence and complications of afibreducing the occurrence and complications of afib Primary prevention of atrial fibrillation Primary prevention of atrial fibrillation

Anticoagulation RecommendationsAnticoagulation Recommendations

AF May Affect Stroke SeverityAF May Affect Stroke SeverityAF May Affect Stroke SeverityAF May Affect Stroke Severity

1061 patients admitted with acute 1061 patients admitted with acute ischemic strokeischemic stroke 20.2% had AF20.2% had AF

Bedridden stateBedridden state With AFWith AF 41.2%41.2% Without AFWithout AF 23.7%23.7%

Odds ratio for bedridden state following stroke Odds ratio for bedridden state following stroke due to AF 2.23 (95% CI, 1.87-2.59; due to AF 2.23 (95% CI, 1.87-2.59; PP<.0005)<.0005)

P<.0005

Dulli et al. Dulli et al. NeuroepidemiologyNeuroepidemiology. 2003;22:118-123.. 2003;22:118-123.

Major Anticoagulation Trials in Atrial Major Anticoagulation Trials in Atrial FibrillationFibrillation

SPAFSPAF11 SStroke troke PPrevention in revention in AAtrial trial FFibrillationibrillation

BAATAFBAATAF2 2 BBoston oston AArea rea AAnticoagulation nticoagulation TTrial for rial for AAtrial trial FFibrillationibrillation

CAFACAFA3 3 CCanadian anadian AAtrial trial FFibrillation ibrillation AAnticoagulationnticoagulation

AFASAKAFASAK44 Copenhagen InvestigatorsCopenhagen Investigators

SPINAFSPINAF55 SStroke troke PPrevention revention iin n NNonrheumaticonrheumaticAAtrial trial FFibrillationibrillation

1 Circulation. 1991;84:527-539.2 N Engl J Med. 1990;323:1505-1511.3 J Am Coll Cardiol. 1991;18:349-355.

4 The Lancet. 1989;1:175-178.5 N Eng J Med. 1992;327:1406-1412.

CHADS2 ScoreCHADS2 Score

Risk FactorRisk Factor ScoreScore

CHFCHF 11

HypertensionHypertension 11

Age > 75 yearsAge > 75 years 11

DiabetesDiabetes 11

Stroke/TIAStroke/TIA 22

Gage, B. F. et al. JAMA 2001;285:2864-2870

CHADS2 Score and CVA RiskCHADS2 Score and CVA Risk

Anticoagulation Recommendations for Anticoagulation Recommendations for Atrial Fibrillation - 2006Atrial Fibrillation - 2006

Anticoagulation Recommendations for Anticoagulation Recommendations for Atrial Fibrillation - 2006Atrial Fibrillation - 2006

Risk CategoryRisk Category Recommended TherapyRecommended Therapy

No risk factorsNo risk factors

CHADSCHADS22 = 0 = 0

Aspirin, 81-325 mg/dAspirin, 81-325 mg/d

One Moderate Risk FactorOne Moderate Risk Factor

CHADSCHADS22 = 1 = 1

Aspirin, 81 mg-325 mg/d or Aspirin, 81 mg-325 mg/d or Warfarin – target INR 2.5Warfarin – target INR 2.5

CHADSCHADS22 >> 2 or mitral 2 or mitral

stenosisstenosisWarfarin – target INR 2.5Warfarin – target INR 2.5

Prosthetic valveProsthetic valve Warfarin – target INR 3.0Warfarin – target INR 3.0

Afib GuidelinesOAC Contraindicated Pt

Afib GuidelinesOAC Contraindicated Pt

In patients in whom OAC therapy is In patients in whom OAC therapy is contraindicated, combination of Plavix and contraindicated, combination of Plavix and Aspirin is recommended to reduce risk of Aspirin is recommended to reduce risk of thromboembolic complicationsthromboembolic complications

IIb indicationIIb indication

ACC/AHA/HRS Guidelines 2011ACC/AHA/HRS Guidelines 2011

CHADS2 VASc ScoreCHADS2 VASc Score

Risk FactorRisk Factor ScoreScore

CHFCHF 11

HypertensionHypertension 11

Age > 75Age > 75 11

DiabetesDiabetes 11

Stroke/TIAStroke/TIA 22

Vascular disease (MI,PVD)Vascular disease (MI,PVD) 11

Age 65-74Age 65-74 11

Sex Category FemaleSex Category Female 11

CHADS2 VASc Stroke RateCHADS2 VASc Stroke Rate

ESC Guidelines 2010ESC Guidelines 2010

Lip G Y H et al. Chest 2011;139:738-741

ESC Guidelines – Anticoagulant TxESC Guidelines – Anticoagulant Tx

Predicting Bleeding RiskHAS-BLED Score

Predicting Bleeding RiskHAS-BLED Score

Hypertension (>160 mmHg systolicHypertension (>160 mmHg systolic 11

Abnormal Renal/Hepatic functionAbnormal Renal/Hepatic function 1-21-2

StrokeStroke 11

Bleeding history or anemiaBleeding history or anemia 11

Labile INR (TTR < 60%)Labile INR (TTR < 60%) 11

Elderly (age > 75 years)Elderly (age > 75 years) 11

Drugs/ETOH (antiplatelet/NSAIDs)Drugs/ETOH (antiplatelet/NSAIDs) 1-21-2

High Risk (>4%/year)High Risk (>4%/year) >4>4

Moderate Risk (2-4%/year)Moderate Risk (2-4%/year) 2-32-3

Low Risk (<2%/year)Low Risk (<2%/year) 0-10-1Pisters, R et al. Chest 2010Pisters, R et al. Chest 2010

New Oral AnticoagulantsNew Oral Anticoagulants

AgentAgent DabigatranDabigatran RivaroxabanRivaroxaban ApixabanApixaban EdoxabanEdoxaban

RouteRoute OralOral OralOral OralOral OralOral

TargetTarget ThrombinThrombin FXaFXa FXaFXa FXaFXa

DosingDosing BIDBID QDQD BIDBID QDQD

LabsLabs NoNo NoNo NoNo NoNo

T1/2T1/2 12-1712-17 9-129-12 8-158-15 8-118-11

EliminateEliminate Renal 80%Renal 80% Renal/HepRenal/Hep Ren/HepRen/Hep RenalRenal

Cumulative Mortality From Any Cause in the Rhythm-Control Group and the Rate-Control Group

Cumulative Mortality From Any Cause in the Rhythm-Control Group and the Rate-Control Group

No. of DeathsNo. of Deaths number (%)number (%)Rhythm controlRhythm control 00 80 (4)80 (4) 175 (9)175 (9) 257 (13)257 (13) 314 (18)314 (18) 352 (24)352 (24)Rate controlRate control 00 78 (4)78 (4) 148 (7)148 (7) 210(11)210(11) 275 (16)275 (16) 306 (21)306 (21)

AFFIRM Investigators NEJM 2002: 347;23AFFIRM Investigators NEJM 2002: 347;23

•Study design: Randomized trial comparing rate vs rhythm controlStudy design: Randomized trial comparing rate vs rhythm controlin patients with Afib and EF<35%in patients with Afib and EF<35%

•1376 patients from 123 centers1376 patients from 123 centers

•Primary endpoint – Death from cardiovascular causesPrimary endpoint – Death from cardiovascular causes

Afib and CHF Investigators Afib and CHF Investigators Primary Endpoint ResultsPrimary Endpoint Results

NEJM June 2008NEJM June 2008

Optimal Rate Control TherapyAfib Guidelines Focused UpdateOptimal Rate Control Therapy

Afib Guidelines Focused Update

Treatment to achieve strict heart rate control Treatment to achieve strict heart rate control (<80 bpm resting, <110 bpm during exercise) is (<80 bpm resting, <110 bpm during exercise) is notnot beneficial compared to achieving a resting beneficial compared to achieving a resting heart rate < 110 bpm.heart rate < 110 bpm.

New recommendationNew recommendation

Rhythm Control vs Heart Rate Control

Rhythm Control vs Heart Rate Control

““Reasons for restoration and maintenance of Reasons for restoration and maintenance of

sinus rhythm in patients with AF include relief sinus rhythm in patients with AF include relief

of symptoms, prevention of embolism, and of symptoms, prevention of embolism, and

avoidance of cardiomyopathy.”avoidance of cardiomyopathy.”

ACC/AHA/ESC AF Guidelines, 2001ACC/AHA/ESC AF Guidelines, 2001

Rhythm Control vs Heart Rate Control

Rhythm Control vs Heart Rate Control

““An effective method for maintaining sinus An effective method for maintaining sinus

rhythm with fewer side effects would address rhythm with fewer side effects would address

a presently unmet need”a presently unmet need”

ACC/AHA/ESC AF Guidelines, 2006ACC/AHA/ESC AF Guidelines, 2006

Symptomatic Atrial Fibrillation!!Symptomatic Atrial Fibrillation!!Symptomatic Atrial Fibrillation!!Symptomatic Atrial Fibrillation!!

Wann, L. S. et al. J Am Coll Cardiol 2011;57:223-242

Focused GuidelinesMaintaining Sinus Rhythm

Focused GuidelinesMaintaining Sinus Rhythm

Expectations of Antiarrhythmic Drug Therapy in Treatment of AFExpectations of Antiarrhythmic Drug Therapy in Treatment of AF

Complete suppressionComplete suppression Best, but AF recurrence likely (Best, but AF recurrence likely (>>50% of 50% of

patients)patients) Recurrence, per se, is not failure of Recurrence, per se, is not failure of

therapytherapy Frequency of recurrenceFrequency of recurrence

More realistic measure of efficacyMore realistic measure of efficacy May vary from patient to patientMay vary from patient to patient

ACE/ARB Antiarrhythmic PropertiesACE/ARB Antiarrhythmic PropertiesACE/ARB Antiarrhythmic PropertiesACE/ARB Antiarrhythmic Properties

•Healey, et al JACC 2005Healey, et al JACC 2005

•Meta-analysis of randomized trials involving ACE/ARB Meta-analysis of randomized trials involving ACE/ARB therapytherapy

•Included trials if atrial fibrillation events were followed as Included trials if atrial fibrillation events were followed as endpointsendpoints

•11 Trials/56,308 patients – 4 CHF, 3 Htn, 2 post CV, 2 post 11 Trials/56,308 patients – 4 CHF, 3 Htn, 2 post CV, 2 post MIMI

•Overall risk reduction of AF occurrence 28% (greatest benefit Overall risk reduction of AF occurrence 28% (greatest benefit seen in CHF patients, limited benefit in hypertensive patients)seen in CHF patients, limited benefit in hypertensive patients)

Curative Ablation for Curative Ablation for Atrial FibrillationAtrial Fibrillation

Curative Ablation for Curative Ablation for Atrial FibrillationAtrial Fibrillation

Appropriate for Patients Appropriate for Patients

•With symptomatic paroxysmal or persistent atrial fibrillationWith symptomatic paroxysmal or persistent atrial fibrillation

•Who are intolerant of drug therapyWho are intolerant of drug therapy

•Who have frequent ambient atrial ectopic activityWho have frequent ambient atrial ectopic activity

•Who have tachycardia mediated tachycardiaWho have tachycardia mediated tachycardia

EBCT – Pulmonary Vein/EBCT – Pulmonary Vein/LA ReconstructionLA Reconstruction

EBCT – Pulmonary Vein/EBCT – Pulmonary Vein/LA ReconstructionLA Reconstruction

LSPVLSPV

LIPVLIPVRIPVRIPV

Courtesy: Harbor - UCLA EBCT CenterCourtesy: Harbor - UCLA EBCT Center

Pulmonary Vein Circumferential Pulmonary Vein Circumferential AblationAblation

Pulmonary Vein Circumferential Pulmonary Vein Circumferential AblationAblation

RSPVRSPVSpiralSpiralcathcath

True Pulmonary Vein IsolationTrue Pulmonary Vein IsolationTrue Pulmonary Vein IsolationTrue Pulmonary Vein Isolation

NEJM 2008;359:1778-85NEJM 2008;359:1778-85

•Randomized trial comparing pulmonary vein isolation (41 patients)Randomized trial comparing pulmonary vein isolation (41 patients)to AV node ablation and biventricular pacing (40 patients)to AV node ablation and biventricular pacing (40 patients)

•Drug refractory atrial fibrillation and EF <40%Drug refractory atrial fibrillation and EF <40%

•Composite endpoint included QOL questionnaire, 2D-echo followComposite endpoint included QOL questionnaire, 2D-echo followup and 6 minute walk distanceup and 6 minute walk distance

PABA-CHF InvestigatorsPABA-CHF InvestigatorsComposite ResultsComposite Results

PABA-CHF InvestigatorsPABA-CHF InvestigatorsComposite ResultsComposite Results

NEJM 2008;359:1778-85NEJM 2008;359:1778-85

PABA-CHF InvestigatorsConclusions

PABA-CHF InvestigatorsConclusions

•In patients with EF<40% and symptomatic atrialIn patients with EF<40% and symptomatic atrialfibrillation, pulmonary vein isolation was superior fibrillation, pulmonary vein isolation was superior to AV node ablationto AV node ablation

•In such a population, pulmonary vein isolation shouldIn such a population, pulmonary vein isolation shouldbe considered at experienced centersbe considered at experienced centers

A Rational Approach to the Afib A Rational Approach to the Afib PatientPatient

A Rational Approach to the Afib A Rational Approach to the Afib PatientPatient

What is the pathophysiology of the patient’s Afib?What is the pathophysiology of the patient’s Afib?

What are the patients symptoms?What are the patients symptoms?

Will the patient benefit from cardioversion? SR Will the patient benefit from cardioversion? SR maintenance?maintenance?

Has anticoagulation been considered and implemented?Has anticoagulation been considered and implemented?

Has the patient failed drug therapy?Has the patient failed drug therapy?

Invasive strategy considered for pharmacologic failuresInvasive strategy considered for pharmacologic failures