Goldstein atrial fibrillation1

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Atrial FibrillationIt Doesn’t Have to Be Irregular

Anymore

Edward Goldstein PA-C

Lead Electrophysiology PA.

UCVA Cardiology

Rochester,NY

Disclosure

• None

LEARNING POINTS

What is Atrial Fibrillation?

Why do we care?

Treatment Options:Rate vs Rhythm

Anticoagulation: Coumadin vs NOACs

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Cardiac conduction• How does conduction appear on an

ECG?

• Cardiac conduction results in the mechanical beating of the heart.

– Mechanical beating is created by electrical impulses moving throughout the conduction system

• Specific waves that appear on an ECG correspond both to the mechanical and the electrical depolarization (or repolarization) of a particular area of the heart.

Atrial fibrillationa. Triggers

p. veins

b. Sustainerleft atriumenlargedfibrosed

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Atrial Fibrilation

Rate Varies, ventricular response can be fast or slow

P-P Ratio Chaotic atrial activity

R-R Ratio Irregularly irregular

P wave No discernable p-waves

P:QRS Ratio None

PR interval None

QRS Width Normal, but can have aberrant (wide) complexes

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Is Atrial Fibrillation Important?

• 2.5 million Americans with Atrial Fib

• 88,000 deaths per year

• $16 billion dollars cost to health care per year

Estimated Number of Atrial Fib Cases by 2030

• A) 3 million

• B) 5 million

• C) 7 million

Atrial fibrillation treatment

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Atrial fibrillation

April 2010:March 2010: 1,980,000 hits

March 2011: 2,550,000 hits

January 2012: 9,500,000 hits

Stroke Prevention in Atrial Fibrillation-

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Background

• 30% of ischemic strokes are of unknown mechanism (cryptogenic stroke)

• Detection of AF usually prompts long-term anticoagulation instead of antiplatelet therapy

• Optimal monitoring duration to detect AF is currently undetermined

Objectives of CRYSTAL AF

• To assess whether a long-term monitoring strategy with an insertable cardiac monitor (ICM) is superior to standard medical care for the detection of AF in patients with a cryptogenic stroke at 6 months (primary end point) and 12 months follow-up (secondary end point)

• Determine the proportion of patients with cryptogenic stroke that have underlying AF.

Comparison of Monitoring Strategies

Minimally invasive outpatient procedure

Local anesthetic and no leads orfluoroscopy

15-30 minute procedure

Device can be followed remotely

MRI conditional

3 year device longevity

Continuous Monitoring Arm: Insertion of REVEAL® XT

Standard Monitoring Arm

Cardiac monitoring performed according to local standards, after mandated testing completed

Symptoms consistent with AF were evaluated by study physicians

Reveal LINQ InsertionAnimation-hi-res.mp4


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Primary Endpoint: Detection of AF at 6 monthsICM finds 6x more patients with AF

Rate of detection in ICM arm was 8.4% vs 1.4% in control arm

6 Month EndpointsICM Control

Median time from randomization to AF Detection

41 days 32 days

Patients found to have AF 19 3

% Asymptomatic Episodes 74% 33%

Oral Anticoagulation (OAC) Usage, overall

10.1% 4.6%

OAC use in patients with detected AF 94.7% 66.7%

Recurrent Stroke/TIA 5.2% 8.6%

Proportion of patients with AF ≥ 6 minutes on one day

93.8% N/A

Tests required to detect AF Automatic AF detection

88 ECGs20 24-hour Holters 1 event recorder

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36 Month DataICM Control

Median time from randomization to AF Detection

252 days 72 days

Patients found to have AF 42 5

% Asymptomatic Episodes 81% 40%

Oral Anticoagulation (OAC) Usage, overall

38.5% 8.3%

OAC use in patients with detected AF 90% 80%

Recurrent Stroke/TIA 11.1% 12.7%

Proportion of patients with AF ≥ 6 minutes on one day

94.9% N/A

Tests required to detect AF Automatic AF detection

202 ECGs, 52 Holter Monitors, 1 Event Recorder

ConclusionsContinuous monitoring with Reveal ICM is superior to standard medical care for the detection of AF in patients with a cryptogenic stroke.

The study demonstrated that:

1. Continuous monitoring detected over 7 times more patients with AF at the 12-month end point.

2. When followed for 3 years, 30% of patients in the ICM arm were found to have AF, and only 3% in the Standard Monitoring arm.

3. Short-term monitoring is not sufficient, as the median time to AF detection over 12 months of follow-up was 84 days.

4. 97% of patients who had AF detected were prescribed OAC.

Atrial Fibrillation Update 2015

1. Rate control vs. Rhythm control

2. Who requires anticoagulants and which ones?

3. What is the role of atrial fibrillation ablation?

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Theoretical Benefit of Rhythm Control

• Improved hemodynamics

• Cardiomyopathy

• Relief of symptoms

• Improved exercise tolerance

• Reduced risk of stroke ?

• Avoidance of anticoagulants ?

• more on this later

96% 96%

87% 89%

76% 79%p = 0.058

NO Difference : death, disabling stroke, major bleed,or cardiac arrest

Sinus rhythm maintained in only 63% of rhythm control group

AFFIRM : 5 Year Outcomes

NEJM 2002;347:1825

Survival Rhythm Control Rate Control

1 year

3 year

5 year

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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.

• Typical patient: 69 yo man, no symptoms

Sinus Rhythm

Antiarrhythmic Use

Warfarin Use

Digoxin Use

0.5 1.0 1.5

Risk Ratio0

pValue

<0.0001

0.0005

<0.0001

0.0005

• N Engl J Med 2002; 347: 1825-33.

Stroke Prevention in Atrial Fibrillation-Mortality in Rate vs. Rhythm Control Patients -The AFFIRM Study

2.0

LenientHr < 110 bpm

StrictRest hr < 80Mod exerc hr < 110

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Primary Outcomes

Cardiac deathCHFStrokeSystemic embolismMajor bleedSyncopeSust VTCardiac arrestLife threat compl of antiarrhythmicPacemaker

Secondary Outcomes

Symptoms

LenientHr < 110 bpm

StrictRest hr < 80Mod exerc hr < 110

Most patients in Lenient HR < 100

Rate Control Options• Beta blocker

– Avoid carvedilol-less effective in AV node blockade– Calcium channel blocker

• Verapamil, diltiazem, aoid in patients in CHF

• Digoxin• Not as the sole agent, monitor level, caution in CKD

• Amiodarone• In refractory cases when other approaches fail• Only when other drugs ineffective, long term effects

• Dronedarone– Less effective than amiodarone– Increased mortality in heart failure

• AV junction ablation plus pacemaker

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Date of download: 2/12/2015

Copyright © The American College of Cardiology. All rights reserved.

From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

J Am Coll Cardiol. 2014;64(21):2246-2280. doi:10.1016/j.jacc.2014.03.021

Strategies for rhythm control in patients with paroxysmal∗ and persistent AF.†

*Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation). †Drugs are listed alphabetically. ‡Depending on patient preference when performed in experienced centers. §Not recommended with severe LVH (wall thickness >1.5 cm). ‖Should be used with caution in patients at risk for torsades de pointes ventricular tachycardia. ¶Should be combined with AV nodal blocking agents. AF indicates atrial fibrillation; AV, atrioventricular; CAD, coronary artery disease; HF, heart failure; and LVH, left ventricular hypertrophy.

Figure Legend:

Rhythm Control Agents

• Tikosyn-Dofetilide

need to be hospitalized for 3 days, EKGs

twice a day, avoid QTc prolonging meds

Torsades

Class IC Antiarrythmics

Sotalol, Propafenone, Flecanide

Anti-Coagulation

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How do we determine stroke risk ?

• CHADS2 (Gage, et al.: JAMA 2001)

– 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)

– 1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)

– > 3 points – high risk (5.9-18.2 strokes per 100 patient years)

How do we determine stroke risk ?

• CHADS2 (Gage, et al.: JAMA 2001)

– 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)

– 1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)

– > 3 points – high risk (5.9-18.2 strokes per 100 patient years)

Lip Y, et al. Chest 2010, 137(2):263

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Lip Y, et al. Chest 2010, 137(2):263

CHADS2 vs. CHA2DS2VASc

• CHADS2 score 0: 1.4% events

• CHA2DS2-VASc 0: 0 events

• CHA2DS2-VASc score 1: 0.6% events

• CHA2DS2-VASc score 2: 1.6% events

Stroke Risk in AF Rises With CHADS2 Score

42Fuster V et al. J Am Coll Cardiol. 2011;57(11):e101-e198.

20

5

15

10

0

1.92.8

4.0

5.9

8.5

12.5

18.2

0n=120

1n=463

2n=523

3n=337

4n=220

5n=65

6n=5

CHADS2 Score

Str

oke

Rat

e (%

per

ye

ar)

♦ Adjusted stroke rate was derived from multivariate analysis assuming no use of aspirin

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International Normalised Ratio (INR)

Target INR

(2.0-3.0)

<1.5 1.5–1.9 2.0–2.5 2.6–3.0 3.1–3.5 3.6-4.0 4.1-4.5 >4.50

20

40

60

80

Ev

en

ts /

10

00

pa

tie

nt

yea

rs

Intracranial haemorrhageIschaemic stroke

The anticoagulant effect of vitamin K antagonists are optimized when therapeutic doses are maintained within a very narrow range

• N Engl J Med 2003; 349: 1019-26.

Stroke Prevention in Atrial Fibrillation-Limitations of Warfarin Therapy in Atrial Fibrillation-Narrow Therapeutic Window

INR Above Target6%

Subtherapeutic INR 13%

INR at Target15%

No warfarin65%

• Arch Intern Med 2000; 160: 967.

Stroke Prevention in Atrial Fibrillation-Limitations of Warfarin Therapy in Atrial Fibrillation

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Meta-Analysis to Assess the Quality of Warfarin Control in

AF in the United States

In the United States, AF patients spend only about one-half the time within therapeutic INR. Anticoagulation clinic services are associated with somewhat better INR control compared with standard community care. 55% therapeutic range, “coumadin clinc” 11% better contol

• Analyzed 323 patients with a second ischemic stroke who had known atrial fibrillation at the time of their first stroke, and who had no known contraindications to anticoagulation

• Stroke 2009; 40: 235-40.

Stroke Prevention in Atrial Fibrillation-Limitations of Warfarin Therapy in Atrial Fibrillation-2o Prevention of Strokes in Patients with A Fib

Subtherapeutic INR 39%

INR at Target18%

No warfarin43%

New Anticoagulation Agents

Dabigatran Warfarin Rivaroxaban Warfarin Apixaban Warfarin

Stroke 1.11% 1.69% 1.7% 2.2% 1.27% 1.6%

Major Bleed

3.11% 3.36% 3.6% 3.4% 2.13% 3.09%

HS 0.1% 0.38% 0.5% 0.7% 0.24% 0.47%

Mortality 3.64% 4.13% 4.9% 4.5% 3.52% 3.94%

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Comparision of New AgentsThromb Haemost 2012(3):476-84

• Odd ratio of stroke Rivaroxaban vs Dabigatran 1.35 (p =0.04).

• Odd ratio of bleeding Apixaban vs Dabigatran 0.74 (p=0.004).

• Odd ratio of bleeding Apixaban vs Rivaroxaban 0.68 (p<0.001).

• No difference between Dabigatran vs Apixaban for stroke.

• Apixaban has less major bleeding.

Comparision of New AgentsHarenberg J et al. Int Angiol 2012(14):330-9

• Apaxiban and Dabigatran superior to rivaroxaban in preventing stroke.

• Apaxiban is safer.

• Higher risk of MI in Dabigatran.

• Apixaban may offer the best benefit-risk balance.

• Dabigatran may be preferred for high risk patient.

Aristotle

• For every 1000 patients treated for 1.8 year, apixaban will prevent

. Stroke in 6 patient.

. Major Bleed in 15 patient.

. Death in 8 patient.

. NNT for Death 239.

. NNT for Major Bleed 105.

. NNT for Stroke 304.

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Who should remain on warfarin?

• Patient already receiving warfarin and stable whose INR is easy to control

• If dabigatran, rivaroxaban, apixaban not available

• Cost

• If patient not likely to comply with twice daily dosing (Dabigatran, Apixaban)

• Chronic kidney disease (GFR < 30 ml/min)

How about Clopidogrel + Aspirin ?

N Engl J Med online publication March 31, 2009

How about Clopidogrel + Aspirin ?

N Engl J Med online publication March 31, 2009

Aspirin: stroke 3.4% per yearmajor bleed 1.27% per year

Aspirin + clopidogrel:stroke 2.4% per yearmajor bleed 2.0% per year

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What is new in atrial fibrillation ablation?

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RSPV

RIPV

LSPV

LIPV

3-D Reconstruction From Spiral CT

AP

CS

LSPV

Lasso Catheter Near Os of LSPV

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Anatomic Carto Map of Let atrium – ablation points

From: Dong et al.: Nature Clinical Practice Cardiovacular Medicine 2005, 2, 159-166

Left Atrial Ablation to Encircle the Pulmonary Veins

• 8 mm tip catheter

• 70 watts, 55°C

• Left & right PV’s encircled

• Mitral isthmus

• Line in posterior LA

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Outcome after LA Ablation to Encircle the Pulmonary Veins

72%

77%Paroxysmal

Chronic

When to consider ablation?

• Antiarrhythmic therapy ineffective

• Antiarrhythmic therapy not tolerated

• Symptomatic afib

Case Presentation

• 64 yo female first seen 4 years ago for long h/o palpitations

• -holter, Echo, stress test all normal

• diagnosed as having sleep apnea

• used CPAP faithfully until…

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Case Presentation

• … had a URI and stopped

• Seen in ED, awoke from sound sleep, thought she may have had palpitations, but did have CP 6/10 , dysarthria and mild facial droop

• All symptoms had resolved by the time she got to ED

Case #1

• EKG NSR, tele in hosp remained in NSR

• Trop 8, CT, MRI head negative

• Cath-no cardiac disease, Echo normal EF, normal valves

• Discussed with neurology and loop recorder placed

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Case Presentation #2

• 62 yo male, no cardiac history, only history is BPH on Flomax

• Retiring as chief of police, small city outside Philadelphia, got his PHD, teaching small college upstate NY, going for a routine physical for D1 baseball umpire

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• What would you do?

• Aspirin started


• What did we do?

• Started Xarelto

• Scheduled Echo, stress test, scheduled TEE, CV

• Told him he may eventually need a pacemaker

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• TEE

• since hadn’t been on anti-coagulation, even though low risk, R/O thrombus

• Xarelto

• after Cardioversion, atria are “stunned” may not contract, raises risk for thrombus formation

• If no recurrent AF after 4 weeks change to ASA

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Goldstein atrial fibrillation1

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