Managing Patients with Atrial Fibrillationcontrol in patients with atrial fibrillation • Review...
Transcript of Managing Patients with Atrial Fibrillationcontrol in patients with atrial fibrillation • Review...
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Managing Patients with Atrial Fibrillation:
Jonathan C. Hsu, MD, MASAssociate Clinical ProfessorDivision of Cardiology, Section of Cardiac ElectrophysiologyJune 29, 2019
Rate versus Rhythm Control and the Use of LAAO Devices to Prevent Embolic Complications
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• Honoraria• Medtronic, Abbott, Boston Scientific, Biotronik,
Janssen Pharmaceuticals, Bristol-Myers Squibb
• Research Grants• Biosense Webster, Biotronik
• Equity• Acutus Medical
Disclosures
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• Evaluate the importance and options for considering rate versus rhythm control in patients with atrial fibrillation
• Review novel therapy options for stroke risk reduction (left atrial appendage occlusion) in patients with AF
Objectives
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• Atrial fibrillation (AF) is the most common cardiac arrhythmia
• In those older than 40 years of age, an estimated 1 in 4 lifetime risk
• Large projected increase in prevalence by the year 2050
Background
Lloyd-Jones DM, Wang TJ, Leip EP, et al. Circulation 2004;110:1042-6.Go AS, Hylek EM, Phillips KA, et al. Jama 2001;285:2370-5.
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Two Pillars of AF ManagementRate vs. Rhythm Control
(Symptoms)OAC vs. LAAO
(Stroke Risk Stratification)
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Medical Management of Atrial FibrillationControlling the ventricular rate and/or attempted maintenance of sinus rhythm
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• Two main therapeutic strategies• Rate control
• Slow conduction of the ventricular response of AF through the AV node
• Rhythm Control• Often cardioversion, with maintenance of sinus
rhythm with anti-arrhythmic drugs
AF: Rate vs. Rhythm Control
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• Almost everyone with a diagnosis of persistent AF deserves at least 1 attempt at maintaining sinus rhythm• Cardioversion + antiarrhythmic drug• Catheter ablation
• Atrial fibrillation has been associated with:• Heart failure• Mortality• Dementia
Key Points
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• In AF, ventricular rate is controlled by conduction properties of AV node• In untreated AF, ventricular rate can be high
• Main reasons for rate control• Avoidance of hemodynamic instability and/or
symptoms• Avoidance of tachycardia-mediated
cardiomyopathy• Some evidence for mortality benefit from rate control
Rate Control Strategy
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Rate Control
January, et al. JACC 2014
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Rate Control Agents
January, et al. JACC 2014
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• Beta Blockers• Widely used as primary therapy for rate control
• Decrease resting heart rate• Blunt heart rate esponse to exercise
• Additional properties- more preferable• AF with reduced LVEF, may improve LVEF and
decrease hospitalization for CHF and death
• Calcium Channel Blockers• Verapamil and diltiazem- negative inotropy
• Caution in Heart Failure
Rate Control Agents
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• Digoxin• Generaly not as effective as BB or CCB• Concern for association with higher mortality in
observational studies• Often reserved for patients with AF and CHF
• Amiodarone• Rhythm control agent, but can slow the
ventricular rate• Often used in critically ill patients, hypotension• Long-term risk of side effects- 2nd line for rate
control
Rate Control Agents
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Rhythm Control Strategy• Persistent symptoms
• Palpitations, dyspnea, light-headedness, heart failure
• Despite adequate rate control
• Inability to attain adequate rate control• Patient preference
• Symptoms• Association with heart failure, other outcomes
such as mortality
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Class IA Agents- Rarely Used
January, et al. JACC 2014
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Class IC Agents
January, et al. JACC 2014
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• Caution in heart failure population• Particularly depressed LV function
• Caution in CAD population• Best to use AV nodal blocking agent in
addition• Can organize to atrial flutter (slower), and have
1:1 conduction to the ventricle
Class IC Agents
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Class III Agents
January, et al. JACC 2014
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• Very frequently used, especially in critically ill and CHF population
• Drug Interactions• Coumadin• Many other drugs
• Monitor for organ toxicity, particularly long term• Thyroid• Liver• Lung
Amiodarone
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Class III Agents
January, et al. JACC 2014
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• Requires hospital stay• Usually 3 days, 5 doses
• Drug Contraindications• Verapamil• HCTZ• Azoles• Bactrim (Trimethoprim)
• Dose adjustment and be careful• Renal dysfunction• QT prolongation
Dofetilide
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Class III Agents
January, et al. JACC 2014
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Køber L, et al. N Engl J Med. 2008;358(25):2678-2687.
ANDROMEDA: Study Primary Endpoint and Results
• Primary endpoint• The primary composite endpoint was all-cause
mortality or hospitalization for HF vs placebo• Results Analysis Up to Study Discontinuation
Placebo(n = 317)
Dronedarone 800 mg/day(n = 310)
Number of patients who died 12 25
Relative risk (relative to placebo) 2.1395% CI 1.07, 4.25
P value .03
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Class III Agents
January, et al. JACC 2014
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• Consider hospital stay• Loading like Dofetilide, many start as outpatient
• Dose adjustment and be careful• Renal dysfunction• QT prolongation
• Caution in LVH (Interventricular septum 1.5 cm or greater)
• Safe to use in coronary artery disease
Sotalol
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Rhythm Control Strategy
January, et al. JACC 2014
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• Best proven way to maintain sinus rhythm in patients with AF• Symptomatic relief• Reduction in heart failure• Can be done safely
Catheter Ablation
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• Targets• Elimination of triggers
• Most commonly triggers from pulmonary veins
• Modifying atrial substrate responsible for AF maintenance
• Goal• Improve patient
symptoms• AF burden reduction
Atrial Fibrillation Ablation
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Packer D, et al. JAMA 2019.
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CABANA Quality of Life
Mark DB, et al. JAMA 2019.
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AFFIRM
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Stroke Risk Reduction in Atrial FibrillationOral Anticoagulation and Left Atrial Appendage Occlusion
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• AF is the most common cause of embolic stroke1
• 15% of all strokes in the US can be attributed to AF1
• AF is associated with an increase in mortality, from 1.3-2 times2
AF and Stroke
1. Nattel. Lancet 2006;367:262-2722. Page. N Engl J Med 2004;351:2408-16
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AF and Stroke
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Appropriate Prescription of OAC Across the Spectrum of Stroke Risk in AFHow are cardiovascular specialists in the United States doing in the real world?
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• CHA2DS2-VASc ≥2• Oral anticoagulation with warfarin or NOAC
• CHA2DS2-VASc =1• Oral anticoagulation with warfarin or NOAC or• ASA • Consider bleeding risk, compliance, patient
preference
• CHA2DS2-VASc =0• No therapy or ASA
Therapy Summary- The New
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Hsu JC, et al. JAMA Cardiology 2016.
• >400,000 patients with AF• Large, real-world population• 2008-2012• >100 practices, academic + private• Treated by cardiologist
Lack of Appropriate OAC
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Hsu JC, et al. JAMA Cardiology 2016.
Oral Anticoagulant Use Does Not Top 50%, Even in the Highest Stroke Risk AF Patients
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Hsu JC, et al. JACC 2016.
38-40% of patients at moderate to high risk of stroke treated with Aspirin alone, not OAC!
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Hsu JC, et al. Clin Pharmacol Ther. 2018.
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Left Atrial Appendage Occlusion Devices for Stroke Prevention in AFAn opportunity to fill treatment gaps in stroke risk reduction practices?
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Kim et al. Am J Cardiol 2010; 106:1174-81.
Role of LAASource of over 90% of thrombus in
nonvalvular AF
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• One of the main goals with AF treatment:• Reduce the rate of systemic embolism
• Particularly stroke• Most patients require chronic anticoagulation
• Except those deemed to be at very low risk for embolic events
• Not all AF patients can, or are willing to take oral anticoagulation despite risk of stroke
Background
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• Manufactured by Boston Scientific• Recent FDA approval 3/13/15• Left atrial appendage occlusion device
• Implanted with transseptal puncture and TEE guidance
• Goal• Reduce stroke risk• Comparator
• Warfarin anticoagulation
LAA Occlusion- WATCHMAN
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PROTECT-AF Long Term F/U
Reddy VY, et al. JAMA. 2014.
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PROTECT-AF Long Term F/U
Reddy VY, et al. JAMA. 2014.
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• Increased risk for stroke based on CHADS2 or CHA2DS2-VASc scores and are recommended for anticoagulation therapy
• Are deemed by their physicians to be suitable for warfarin
• Have an appropriate rationale to seek a non-pharmacologic alternative to warfarin
WATCHMAN- FDA Approval
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Summary• Two methods for approaching medical
therapy of AF• Rate control• Rhythm control
• Need to consider stroke risk in patients with AF- OAC vs. LAAO
• Symptoms and patient/physician preference important
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