management of atrial fibrillation

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MANAGEMENT OF ATRIAL FIBRILLATION VINOD G V

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MANAGEMENT OF ATRIAL FIBRILLATION. VINOD G V. Definitions. Paroxysmal AF - self-terminating, usually within 48 h, may continue for up to 7 days. Persistent AF - when an AF episode either lasts longer than 7 days or requires termination by cardioversion . - PowerPoint PPT Presentation

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MANAGEMENT OF ATRIAL FIBRILLATION

VINOD G V

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Definitions

• Paroxysmal AF - self-terminating, usually within 48 h, may continue for up to 7 days.

• Persistent AF - when an AF episode either lasts longer than 7 days or requires termination by cardioversion.

Long-standing persistent AF has lasted for ≥1 year when it is decided to adopt a rhythm control strategy.

Permanent AF-DC version failed or not attempted• Recurrent AF-has had 2 or more episodes

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“lone AF” • generally applies to young individuals under

60 y of age without clinical or echocardiographic evidence of cardiopulmonary disease including hypertension .

• have a favorable prognosis with respect to thromboembolism and mortality.

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Haemodynamics

• Loss of atrial contraction• A rapid ventricular rate• An irregular ventricular rhythm

• Loss of mechanical AV synchrony affects ventricular filling esp. when left ventricle has reduced compliance.

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• 3 objectives

Rate control

prevention of thromboembolism

correction of the rhythm disturbance,

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Type and duration of AF

Severity and type of symptoms

Associated cardiovascular disease

Patient Age

Associated medical conditions

Pharmacological and nonpharmacological therapeutic options.

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• Rapid ventricular rate produce symptoms Tachycardia related cardiomyopathy

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Rate control

• Strict rate control: Resting HR -60-80 Moderate exercise 90-110• Lenient HR Resting HR <100

RACE II (RAte Control Efficacy in permanent atrial fibrillation) trial did not identify a benefit of stringent rate control over lenient rate control therapy in 614 patients

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Primary Outcomes

Cardiac deathCHFStrokeSystemic embolismMajor bleedSyncopeSust VTCardiac arrestLife threat compl of antiarrhythmicPacemaker

Secondary Outcomes

Symptoms

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• Beta-Blockers useful in the presence of high adrenergic tone or symptomatic myocardial ischaemia

• Non dihydropyridine CCB-Diltiazem,verapamil • Digoxin-effective at rest ,not during exercise

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Rhythm control

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Theoretical Benefit of Rhythm Control

• Improved hemodynamics• Relief of symptoms• Improved exercise tolerance• Reduced risk of stroke• Avoidance of anticoagulants

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Rhythm control

• Pharmacological

• Non pharmacological Cardioversion Catheter Ablation

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Cardioversion in AF

• Pharmacological

• Electrical cardioversion

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DC Cardioversion

• Delivery of an electric shock synchronised with the intrinsic activity of heart by sensing the R wave

• Successful cardioversion depends on Duration of AF Current density delivered to atrial myocardium

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Joglar JA et alAm J Cardio 2000

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Mittal S et al Ciculation 2000

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Elhendy A et al Am J Cardio 2002

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Pharmacological cardioversion

• Simple • Less efficaious• More effective in AF <7 day duration• Problems of drug toxicity

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• AF lasting <1 wk – cardioversion -using oral flecainide, propafenone, dofetilide, and intravenous ibutilide.

• For longer duration- iv dofetilide( also amiodarone and ibutilide may be useful)

• Single oral dose of propafenone or flecainide – in recent onset AF (pill in the pocket)

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2 strategies• Oral warfarin with a therapeutic INR (2–3) for 3 to 4

weeks before cardioversion followed by continued warfarin thereafter

• Transesophageal echocardiography (TEE) and heparin immediately before cardioversion followed by oral warfarin thereafter.

• Left atria – stunning effect. So anticoagulation is to be continued for 4 wks

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AF upto 7 days

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AF >7 days

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Pharmacological Rhytm control

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Major Trials Comparing Rhythm Strategy and Rate Strategy

Major trials include:– AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management )– RACE (rate control versus electrical cardioversion)– PIAF (pharmacological intervention in AF)– AF-CHF

Major overall findings: – Rhythm-control strategy was not superior to rate-control strategy in terms of

morbidity/mortality– Appropriate choice of therapy should be based on each patient’s symptoms and

disease– rate control, prevention of thromboembolism, and correction of the rhythm

disturbance - these strategies are not mutually exclusive

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AFFIRM : 5 Year Outcomes

Survival Rhythm control Rate control

1yr 96 96

3yr 87 89

5yr 76 79

NO DIFFERENCE:Death, major bleed ,disabling stroke,cardiac arrest

Sinus rhythm maintained in only 63% of rhythm control group

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AFFIRM Trial

• No survival advantage to rhythm control.• Rhythm control patients were more likely to be

hospitilized with adverse drug effects.• Both groups had similar stroke risk (1% per yr)

– Majority of strokes when warfarin stopped or INR subtherapeutic– Warfarin required long term even if sinus rhythm restored

• Torsades, bradycardic arrest more common with rhythm control.

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• Attempts at restoration of sinus rhythm not always successful– AFFIRM Trial: only 63% of “rhythm control” group were in sinus

rhythm– Antiarrhythmics used to maintain sinus rhythm associated with a

25-50% annual failure rate.

• Long term anticoagulation not mandated in the “rhythm control” group– Those in afib at risk for stroke

• Medications used to maintain sinus rhythm risk of proarrhythmia and other toxicity

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Vernakalant

• Acts preferentially in atria• Blocking several ion channels• Prolongation of atrial refractoriness• Rate dependent slowing of atrial conduction• Little impact on ventricular repolarization

Pharmacological cardioversion of AF <7 days or <3days for patients after cardiac surgery

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AVRO• Double-blind,active-controlLed -i.v. amiodarone• N=232 Vernakalant n = 116, Amiodarone n = 116• Hypertension(71.6%) ischaemic heart disease(22.4%)

myocardial infarction (8.2%) heartfailure(19.8%)(NYHA I- 45.7%, NYHA54.3%) valvular heart disease, 6.9%

• AF 3–48 h (median 17.7 h) Time to conversion 11m• Conversion to SR- 51.7% vs. 5.2% P <0.0001• Reduction in symptoms at 2 h reported by 53.4%

patients in the vernakalant groupvs. 32.8% in the Amiodarone group P = 0.0012

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“Pill in the Pocket” strategy

• Preferred in– Paroxysmal AF with no structural heart disease– Self administration of a single oral dose of drug

shortly after the start of palpitations– Decrease hospital visitsPropafenone 450-600mgFlecainide 200-300mg

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Anti-arrhythmic drugs for maintaining sinus rhythm

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Selection of specific agent depends on underlying cardiac disease

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CATHETER ABLATION IN AF

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Factors

• Factors that trigger

• Factors that perpetuate

• Triggering foci of rapidly firing cells within the sleeve of atrial myocytes extending into the pulmonary veins - shown to be the underlying mechanism of most paroxysmal AF

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When to consider ablation?

• Antiarrhythmic therapy ineffective

• Antiarrhythmic therapy not tolerated

• Symptomatic afib

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• The stage of atrial disease ( AF type, LA size, AF history)

• The presence and severity of underlying cardiovascular disease

• Potential treatment alternatives (antiarrhythmic drugs, rate control)

• Patient preference

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• Anatomic ablation

• Electrogram guided ablation

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Anatomic Carto Map of Lett atrium ablation points

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Ablation may be a first strategy

• Patient very symptomatic in AF and refuses antiarrhythmic drug therapy

• Young patient whose only effective antiarrhythmic drug is amiodarone

• Patient with significant bradycardia for whom antiarrhythmic drug therapy will require pacemaker

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Results

• Difficult to interpret– Success rate

• Optimal patient: – single procedure 60 - 80%– Multiple procedures 80 – 90%– Poor patient (eg 3 years persistent afib, sig enlarged LA

– Best success with paroxysmal and healthy heart– Least success with chronic and diseased left atrium– May recur despite initial success– May recur without symptoms

• Ultimate goal: Rhythm control without toxic antiarrhythmics

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• Complication rate 1-5%– Tamponade – atrial perforation– TIA, stroke– Major bleed– Creation of atrial flutter (up to 8%)– Vascular access complications– Pulmonary vein stenosis (lower incidence than initial)– Aorto-esophageal fistula– Fatal 1/1000

• Lengthy procedure– 4-5 hours

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Risk factors for recurrence of afib

Long-term persistent afibValvular heart diseaseDilated cardiomyopathy

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Anti Thrombotic therapy

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Risk stratification

• CHADS2 – Congestive heart failure - 1pt– Hypertension - 1pt– Age > 75 - 1 pt– Diabetes - 1pt– Stroke or TIA - 2 pts

– 0 points – low risk (1.2-3.0 strokes per 100 patient years)– 1point– moderate risk (2.8-4.0 strokes per 100 patient years)– > 2 points – high risk (5.9-18.2 strokes per 100 patient years)

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CHA2DS2-VASC

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Anticoagulation strategy

• CHADS2 score 0 No anti thrombotic therapy• CHADS2 score 1 Aspirin 75-325 mg daily Oral anti coagulation• CHADS2 score 2 Oral anti coagulation

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Anti thrombotic therapy

• VKA eg: warfarin

• Antiplatelets eg aspirin,clopidogrel

• Newer oral anti coagulants Direct thrombin inhibitor-Dabigatran Fa Xa inhibitors-Apixaban,Rivaroxaban

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Warfarin

• Effective• Reversible• Inexpensive

• Slow onset of action• Regular monitoring• Food interraction• Medication interraction• Difficult titration-regular dose adjustments

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Aspirin

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Clopidogrel + Aspirin ?

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• Aspirin:

stroke 3.4% per year

major bleed 1.27% per year

• Aspirin + clopidogrel:

stroke 2.4% per year

major bleed 2.0% per year

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New anticoagulants

• Short half life – less bleeding

• Lack of need for routine monitoring

• Generally safer than warfarin– No antidote

• Cost of medication– Overall cost of care

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Apixaban (Aristotle trial)

• Twice daily: 5mg BD• Less hemorrhagic stroke than warfarin• Similar reduction in ischemic stroke• Less bleeding than warfarin• Lower overall mortality• No routine lab testing• No reversal

– Half life 8-15 hours

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Dabigatran(RELY trial)

• Dabigatran 110 mg twice daily– Equal to warfarin in stroke prevention

• Warfarin 1.69%/yr – dabigatran (110mg) 1.53%/yr– Less bleeding than warfarin

• Warfarin 3.36%/year – dabigatran (110mg) 2.71%/yr

• Dabigatran 150 mg twice daily– More effective than warfarin in stroke prevention

• Dabigatran (150mg) 1.11%/yr– Equivalent bleeding to warfarin

less hemorrhagic stroke than warfarin

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Rivaroxaban (Rocket AF trial)

• Once daily: 20 mg• Less hemorrhagic stroke than warfarin• Similar reduction in ischemic stroke• Less bleeding than warfarin• No routine lab testing• No reversal

– Half life 5-9 hours

• Discontinuation : increased stroke

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• CHADS2 score includes all except1.TIA2.Age > 60 yrs3.DM4.Congestive heart failure

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• 55 yr old man with AF , no h/o HTN,DM ,no structural heart disease TRUE regarding antithrombotic therapy

1.Aspirin 150 mg OD2.Warfarin 2mg 3.Dabigatran 150 mg BD4.No antithrombotic therapy needed

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• 30 yr old patient presented to emergency department with 2hr h/o palpitation ,ECG showing wide complex irregular tachycardia rate 200/min preferred method of treatment

1.IV Verapamil2.IV Diltiazem3.IV Digoxin4.IV Procainamide

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• Drug used in “pill in the pocket strategy”1.Sotalol2.Propafenone3.Ibutalide4.procainamide

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• True about Dabigatran except1.RE-LY trial evaluated dabigatran2.Two doses were evaluated in RE-LY trial3.Rate of haemorragic stroke more compared to

warfarin4.Dose adjustment needed in CKD

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• CHA2DS2 VASc score includes all except1.Age 65-74 yrs2.Male sex3.Atherosclerotic plaque in aorta4.HTN

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• Drug prefered for maintainance of sinus rhythm in structurally abnormal heart is

1.Sotalol2.Betablockers3.Amiodarone4.Ibutalide

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Rivaroxaban true except1.Rivaroxaban better than warfarin in reducing

stroke in AF 2.20 mg twice daily3.Less haemorrhage than warfarin4.Evaluated in ROCKET AF trial

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• VERNAKALANT all are true except1.Acts preferentially in atria2.Causes significant QT prolongation3.Used in post operative AF conversion4.Contraindicated in heart failure

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• Apixaban TRUE EXCEPT1.Direct thrombin inhibitor2.Evaluated in ARISTOTLE trial3.Cause less haemorrhage than warfarin4.Non inferior to warfarin in stroke prevention