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Steven Heifetz, MD FACC UMP-Heart

(don’t be afraid of the big bad “WOLF”)

Normal Sinus Rhythm (NSR): “RRR”, coordinated, regular rhythm

The “definitive” way to diagnose Afib – EP Lab

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EP STUDY: Normal Sinus Rhythm (NSR)

Intra-cardiac electrogram and

Surface 12 lead ECG

EP STUDY: Atrial fibrillation

Intra-cardiac electrogram and

Surface ECG

The “usual” way to diagnose afib-

12 Lead ECG.

But…what happens if it paroxysmal?

Classic hallmark: Rapid and irregular (but not always! -eg: already on beta blocker, AV node disease)

81 YO WM-

LIVES ALONE, MULTIPLE “FALLS” OVER

PAST SIX MONTHS.

LAST EPISODE WITNESSED BY FAMILY--

SYNCOPE? PATIENT ADMITTED FOR

WORK UP.

FAMILY REPORTS GENERAL DECLINE

IN THEIR FATHER’S HEALTH, WONDERS

ABOUT NURSING HOME PLACEMENT.

CASE PRESENTATION #1

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EXAM:

AFEBRILE, 162/68 (NO ORTHOSTASIS), 66

LUNGS-CLEAR

COR- RRR, Gr II/VI SEM

CAROTIDS- NORMAL UPSTROKE, SOFT BRUIT (L)

CNS- NON FOCAL, EARLY DEMENTIA?

LABS: ELECTROLYTE-UNREMARKABLE CBC-UNREMARKABLE CXR-MILD HYPERINFLATION, Ca++ AORTIC BULB HEAD CT- ATROPHY EKG-NSR, LAD ECHO-MILD LVH, NORMAL EF, AORTIC SCLEROSIS TELEMETRY (ON CSC)- UNREMARKABLE

PATIENT DISCHARGED AFTER 48 HOURS

OUT PATIENT HOLTER ORDERED

WHAT DID THE HOLTER SHOW?

WHAT WOULD YOU DO?

Holter monitor: • Continuous 24 hour recording

• Patient “diary”-trigger

• “Post” analysis

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Standard “30 day” Loop recorder:

• Patient activated

• “Auto-record” • “Holds” recording until patient

calls in download via telephone

MCOT: Mobile Cardiac Outpatient

Telemetry • Events are automatically transmitted

to the monitoring center without patient intervention via cell phone technology

External “30 day” Loop recorders

AfibPauseNSR

THE FOLLOWING STRIP WAS OBTAINED

ABOUT THREE WEEKS LATER ON A 30 DAY

LOOP MONITOR WITH AutoRecord,

DURING A “FALL”…

AfibPauseNSRAfib

(Sick Sinus Syndrome/Tachy-Brady)

PAC

Another patient-30 day loop recorder CASE PRESENTATION #2

THE FOLLOWING IS A TRUE STORY…..

really

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A 72 YO WIDOWER GOES INTO A BAR

HE SITS DOWN AT THE BAR AND IMMEDIATELY

BECOMES ASHEN

THE BARTENDER ASKS HIM IF HE IS OK

THE MAN REPLIES “NO” AND ASKS THE BARTENDER--

HAVE YOU HEARD THE ONE ABOUT A GUY WITH

“SPELLS”

THE BARTENDER REPLIES, “YES, I HAD SPELLS

BUT DR. HEIFETZ FIXED THEM”

HE WAS “SELF REFERRED” ON THE RECOMMENDATION OF HIS BARTENDER

HE HAS SEEN NUMEROUS PHYSICIANS IN THE PAST AND HAD NUMEROUS

TESTS INCLUDING-HEAD CT, EEG, ECG, ECHO, HOLTER etc

THE SPELLS OCCUR 1-2/YEAR. THEY COME ON

SUDDENLY AND LAST UP TO 30 MINUTES

HE FEELS WEAK IN HIS LEGS, AND SHAKY. HE HAS NEVER PASSED OUT,

BUT HE FEELS LIKE HE MIGHT. OCCASIONALLY HE IS SOB BUT NEVER

HAS CHEST PAIN. THERE ARE NO TRIGGERS, AND THE EPISODES SUBSIDE

SPONTANEOUSLY. THE EPISODES HAVE BECOME LESS WELL TOLERATED

AS HE HAS GOTTEN OLDER.

HIS EXAM, PMH, AND ROUTINE LABS ARE UNREMARKABLE

THE PATIENT WAS OFFERED A 30 DAY LOOP MONITOR--BUT HE WISELY

POINTED OUT THAT HE WAS UNLIKELY TO HAVE A SPELL IN THE NEXT

30 DAYS. HE REQUESTS A “DEFINITIVE” TEST

THIS 72 YO HAS BEEN HAVING “SPELLS”

FOR ALMOST 22 YEARS

THE PATIENT HAD A COMPLETE

ELECTROPHYSIOLOGY STUDY AND

TILT TABLE STUDY.

THESE TESTS WERE ALL NORMAL

A MEDTRONIC “REVEAL” MONITOR WAS

IMPLANTED SUBCUTANEOUSLY

MEDTRONIC “REVEAL” and “LINQ”

IMPLANTABLE LOOP RECORDER

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SEVEN WEEKS LATER HE REPORTED TO

OUR OFFICE, TO TRANSMIT A CAPTURED “EVENT”

TELEMETRY REVEALED THE FOLLOWING STRIP...

UPON NEWS OF THE DIAGNOSIS, THE PATIENT BEGAN TO CRY.

WHEN ASKED WHY HE WAS CRYING, HE STATED HE WISHED HIS

WIFE WAS STILL ALIVE TO SEE THIS, HE WAS STARTING TO THINK

HE WAS CRAZY AND THERE REALLY WAS NOTHING WRONG WITH HIM,

AS HE HAD BEEN TOLD IN THE PAST

This patient was at a bar and referred in by his

bartender.

This patient was at a bar and referred in by his

bartender.

Perhaps this is an untapped marketing

opportunity.

This patient was at a bar and referred in by his

bartender.

Perhaps this is an untapped marketing

opportunity.

Medical professional groups may want to

consider this in their future direct to consumer

advertising campaigns.

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Reduce morbidity, mortality, and disability from CV & pulmonary diseases through education, prevention, rehabilitation, research, and aggressive disease management

Patient Eligibility

Enrolled after new dual-chamber pacemaker or ICD

Age ≥ 65 years

History of hypertension

Excluded if any history of AF

Excluded if on Vitamin K antagonist

Pre-specified primary analysis:

Monitor from enrolment to 3 month visit for atrial tachyarrhythmia

defined as >6 minutes and an atrial rate of >190 bpm

Prospective follow up for ischemic stroke or systemic embolism from 3

month visit onwards

Statistical power to detect ≥ 1% per year increase in primary outcome

ASSERT Healy S, NEJM 2012; 366:120-9

ASSERT: Study Design

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Panel A shows the risk of

electrocardiographically documented

clinical atrial tachyarrhythmias after the

3-month visit, according to whether

subclinical atrial tachyarrhythmias were

or were not detected between enrolment and the 3-month visit.

Panel B shows the risk of ischemic stroke or

systemic embolism after the 3-month visit,

according to whether subclinical atrial

tachyarrhythmias were or were not detected

between enrollment and the 3-month visit.

The insets show the same data on an

enlarged y axis.

A: Risk of Clinical Atrial Tachyarrhythmias

B: Ischemic Stroke or Systemic Embolism

ASSERT-trial

Over 2.8 years mean follow up, device-detected atrial

tachyarrhythmias (>6 min, >190 bpm) are present in 36% of

pacemaker patients with hypertension; but no prior history of AF

In patients with CHADS2 score > 2, device-detected atrial

tachyarrhythmias increase the absolute risk of stroke or systemic

embolism to 4% per year

Among pacemaker patients without prior AF, 35% of all strokes

or systemic emboli are preceded by device-detected atrial

tachyarrhythmias.

ASSERT Conclusions

Gladstone DJ. N Engl J Med 2014; 370:2467-2477

EMBRACE Investigators: AF in patient with cryptogenic stroke

To determine the diagnostic yield of a 30-day cardiac event monitor compared to a repeat 24-hour Holter monitor for detecting occult paroxysmal atrial fibrillation in patients with a recent ischemic stroke or TIA of undetermined etiology.

• 55 years or older • Experienced ischemic stroke or TIA within previous 6

months • No cause identified by post-stroke/TIA diagnostic workup,

including ECG, 24-hr Holter, brain imaging, and echo. • No history of atrial fibrillation or flutter.

EMBRACE: Primary objective

Study Population

30 day event monitor vs 24 hr Holter

Incremental Yield of Prolonged ECG Monitoring for the Detection of Atrial Fibrillation in

Patients with Cryptogenic Stroke or TIA

EMBRACE Gladstone DJ. N Engl J Med 2014; 370:2467-2477

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• Among patients 55 years or older with a recent cryptogenic stroke or TIA, paroxysmal atrial fibrillation was common.

• Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring.

Conclusions

EMBRACE Gladstone DJ. N Engl J Med 2014; 370:2467-2477 CRYSTAL-AF: Sanna T. N Engl J Med 2014; 370:2478-2486

Cryptogenic Stroke and Underlying AF

• 441 Pts >40 yo, no h/o Afib with cryptogenic stroke.

(“controls”)

• At 12 months detection of AF >30 sec: REVEAL vs ECG: 12.4% vs 2.0% (p <0.001)

Calculate a patient’s stroke risk to determine

who benefits from anticoagulants

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S>R Vitamin K epoxide reductase (VKOR)

VKORC1

GrpA-(Asia, more sens to W so rapid INR inc), Lower W dose

GrpB-(Black, res to inhib by W so need higher W dose)

CYP2C9

S-warf metabolized by 2C9

Among patients with non-valvular

atrial fibrillation, anticoagulation

that results in an INR of 2.0 or

greater reduces not only the

frequency of ischemic stroke but

also its severity and the risk of

death from stroke.

Hylek EM, Go AS, Chang Y, et al N Engl J Med. 2003;349:1019-1026

Effect of intensity of oral anticoagulation on stroke severity and mortality

in atrial fibrillation

As HbA1c is to FBG, TTR is to INR

Figure 4. TTR versus adverse events (weighted by sample size) for retrospective studies.

Wan Y et al. Circ Cardiovasc Qual Outcomes. 2008;1:84-91

Copyright © American Heart Association, Inc. All rights reserved.

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INR vs Date

Fractional Method: 3/5 = 60% TTR

Rosendaal Method: 15/29 = 52% TTR

We changed one INR value (still in the therapeutic range) by 3 days