Post on 12-Nov-2014
description
Atrial Fibrillation: Rate/Rhythm ControlNon Pharmacological Management
Dr Akshay Mehta Dr B Nanavati Hospital Asian Heart Institute
Two most important things to know
Type of AF
Symptoms due to AF
First Diagnosed Episode of AF
Paroxysmal(usually <= 48 h)
Persistent (> 7 days or requires CV)
Long standing Persistent ( >1 year)
Permanent (accepted)
EHRA score of AF-related symptoms
EHRA class Explanation
EHRA I ‘No symptoms’
EHRA II ‘Mild symptoms’; normal daily activity not affected
EHRA III ‘Severe symptoms’; normal daily activity affected
EHRA IV ‘Disabling symptoms’; normal daily activity discontinued
Choosing Rate v/s Rhythm Control
Two types of settings
Acute/Unstable
Non acute/Stable
Acute/Unstable setting
Rate Control Rhythm Control
Cause: underlying cond severe AF Sx orEx- pneumonia, PE, Thyroid h-dynamic instab
No severe AF Sx or h-dynamic instab pharmac cv electric cv
Older age
Large LA
How Rate Control ?
Acute/Unstable setting
Rhythm control – (Sx or hemody instab) Pharmac cv Electrical cv
* <48 hrs *can > 48 hrs * No electrolyte *ischemia imbalance *hypoten * No ECG *HF sign of severe *Preexcited AF with ongoing ishemia instability * Hemodynamic stable + , -
ESC 2012
Recommendations for anticoagulation pericardioversion
………..recommendations for anticoagulation pericardioversion
Non Acute/Stable Setting :
Rate Control v/s Rhythm control
INCLUDES RATE CONTROL
OAC for Both
AIMS of management of AF patients:
• Prevent complications
• Reduce symptoms (palpitations, dyspnoea, fatigue, and dizziness)
antithrombotic therapy control of ventricular rate Rx of associated CV disease
• ± Additional rhythm control therapy by cardioversion, antiarrhythmic drug therapy, or ablation therapy
Randomized trials comparing rate control with rhythm control
• Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) : no difference in all cause mortality (primary outcome) or stroke rate
• The Rate Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) trial :rate control not inferior to rhythm control for prevention of cardiovascular mortality and morbidity (composite endpoint).
• The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial : in patients with an LVEF ≤35%, no difference in
cardiovascular mortality (primary outcome) symptoms of congestive heart failure, or in the secondary outcomes
including death from any cause and worsening of heart failure
However….• These studies enrolled predominantly older patients (average
70 y)
• Most of whom had persistent AF and heart disease,
• Follow-up extended over just a few years
• Pts were at a stage where difficult to maintain sinus rhythm
Hence :
• Data don’t necessarily apply in young
• Must not lose “window” of opportunity due to electrical and
structural remodeling
Hence…
Rate control may be reasonable initial therapy in
older patients with persistent AF with mild
symptoms
For younger individuals, especially those with
paroxysmal lone AF, rhythm control may be a better
initial approach.
When to do Rate Control ?
How to do long-term rate control
How MUCH rate control ?
resting<110/mt
< 80, 110
Rate ControlSymptoms
More strict rate controlExercise test if excessive heart rate is
anticipated during exercise
24 h ECG for safety
No or tolerable symptoms
Accept lenient rate control
Rhythm Control
Rhythm control therapy is reasonable to ameliorate symptoms, in paroxysmal/persistent
AF
When to do Rhythm Control ?
AAD Therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent
atrial fibrillation.
Copyright © American Heart Association
β-Blockers are recommended for prevention of adrenergic AF-I C & should be consideredfor rhythm (+ rate) control in a first episode of AF - IIa
2011 Writing Group Members et al. Circulation 2011;123:104-123
Antiarrhythmic drugs v/s left atrial ablation for rhythm control in AF ESC 2012
Catheter ablation for AF using the CARTO contact mapping system
Recommendations for surgical ablation of AF
Recommendations for LAA closure/occlusion/excision - ESC 2012
Recommendation for atrioventricular node ablation in AF patients
Should be considered When the rate cannot be controlled with pharmacological agents and when AF cannot be prevented by antiarrhythmic therapy or is
associated with intolerable side effects, when direct catheter-based or surgical ablation of AF is not indicated,
has failed, or is rejected. IIa Should be considered for patients with permanent AF and an indication
for CRT (IIa)Should be considered for CRT nonresponders in whom AF prevents
effective biventricular stimulation and amiodarone is ineffective or contraindicated- IIa
• In patients with any type of AF and severely depressed LV function biventricular stimulation should be considered after AV node ablation.
Summary- management of patients with recurrent paroxysmal AF
Recurrent Paroxysmal AF
Minimal or no symptoms
Anticoagulation and rate control* as needed
No drug for prevention of AF
Disabling symptoms in AF
Anticoagulation and rate control as needed
AAD therapy *
AF ablation if AAD
treatment fails
Summary- management of patients with recurrent persistent or permanent AF
Recurrent Persistent AF
Minimal or no symptoms
Anticoagulation and rate control*
as needed
Disabling symptoms in AF
Anticoagulation and rate control
AAD drug therapy
Electrical cardiovers
ion as needed
Permanent AF
Anticoagulation and rate control* as needed
THANK YOU!!!