WHAT THE FIB?Taming Atrial Fibrillation

Pearls for Primary Care Providers

Y. Michelle Fang, MSN, FNP-BC & Shelly de Peralta, DNP, ACNP-BC

OBJECTIVES

• Apply the assessment and evaluation of Atrial Fibrillation to a newly diagnosed patient.

• Identify indications for the use of anticoagulation for stroke prevention in patients with Atrial Fibrillation

• Describe treatment priorities in management of Atrial Fibrillation

• Identify pharmacological and non-pharmacological options for Atrial Fibrillation management

WHY ARE WE TALKING ABOUT ATRIAL FIB?

• Most Common Heart Arrhythmia

• Supraventricular tachy-arrhythmia with atrial depolarization at a rate of 300-600 beats/minute, with variable, sometimes rapid, ventricular depolarization

• Initial diagnosis usually occurs in Primary Care Offices or Urgent Care/Emergency Departments

• 1 in 4 lifetime risk for developing Atrial Fib in adults >40years old

WHY ARE WE TALKING ABOUT ATRIAL FIB?

• Primary Concern à Stroke Prevention

• decreased blood flow velocity in the left atrial appendage resulting in thrombus formation

WHY ARE WE TALKING ABOUT ATRIAL FIB?

• Per the CDC:• Estimated 2.7-6.1 million people in the United States have Atrial Fib• Expected to increase with aging population• ~2% of people <65 years of age and ~9% of people >65 years of age• Greater incidence in Women than Men

• Effect on our healthcare system• More than 750,000 hospitalizations due to Atrial Fib• Contributes to 130,000 deaths per year• Cost per year: $6 billion• Medical costs for people who have Atrial Fib is $8,705 higher per year than people

who do not have Atrial Fib

NEW TECHNOLOGY

MEET THE PATIENT

• A 68 year old female presents for an episodic visit, reporting intermittent palpitations and sensation of “heart racing” for the past week. Denies any history of similar symptoms. Has been going for brisk 2 mile walks, 5 days/ week but for the past week during her walks finds that she gets fatigued more easily. Feels OK today.

• Medical History:• HTN• Type 2 Diabetes – last A1c 6.8%• Chronic left knee pain 2/2 arthritis now s/p Left TKA January 2018• Hypothyroidism

MEET THE PATIENT

• Social History:• Lifetime non-smoker• ETOH intake: 1-2 glasses of wine/week

• Medications:• Atorvastatin 40mg every night• Lisinopril 10mg daily• Metformin XR 500mg daily• Synthroid 125mcg/day• Ibuprofen 400mg PRN pain

PHYSICAL EXAM

• Vital Signs• Blood Pressure: 128/70• Heart Rate: 98 beats per minute• Respiration: 18 breaths per minute• Temperature: 98.2F• Height/Weight: 5ft 6in/165lbs à BMI 26.6• Waist Circumference: 34inches• Accuchek: 120, last meal 3 hours ago

• Exam• General: Alert and oriented, does not appear to be in acute distress• Lungs: CTA bilaterally• Cardiac: rhythm is irregular; no murmurs; no peripheral edema

FIB OR NOT?

Left TKA Pre-Op EKG January 2018

FIB OR NOT?

EKG in Clinic Today

FIB OR NOT?

FIB OR NOT?

COMMON SYMPTOMS

• Palpitations

• Dyspnea

• Fatigue

• Exercise intolerance

• Lightheadedness

• Greater than 60 years of age

• Diabetes

• High Blood Pressure

• Coronary Artery Disease, Prior heart attacks

• Cardiomyopathy, Heart Failure

• Pericardial inflammation

• Structural Heart Disease

• Thyroid Disease

• Chronic Lung Disease

• Sleep apnea

• Excessive alcohol or stimulant use

• Serious illness or infection

RISK FACTORS

WHAT’S NEXT?

• Echocardiogram• Rule out structural/valvular abnormalities• Evaluate size of left/right atria• Evaluate size and function of the Left Ventricle

• Exercise Testing (stress ECHO or MPI)• Rule out ischemia • Evaluating heart rate response to exercise

• Baseline Labs• TSH, CBC, Creatinine, A1c

• Ambulatory ECG Monitoring• Determine classification of Atrial Fibrillation• Evaluate for heart rate control

CLASSIFICATION

• Paroxysmal• Self-terminating or intermittent• May recur in variable frequency

• Persistent• Does not self-terminate within 7 days• May require pharmacological or electrical cardioversion

• Permanent• Persistent Atrial Fibrillation no longer pursuing rhythm control strategy

WHEN DOES A PATIENT GET ADMITTED?

• Signs and symptoms of heart failure

• Poor rate control

• Initiation of anti-arrhythmic drug therapy

• Treatment of primary medical condition/problem

NEW ONSET ATRIAL FIB

• Prevention of systemic embolization• Determine embolic risk, CHA2DS2-VASc score

• Evaluate risk for bleeding, HAS-BLED score

• Rate versus Rhythm Control• Rate Control – slow conduction across the AV node

• Rhythm Control – antiarrhythmic drug therapy, electrical cardioversion, percutaneous catheter ablation, and/or surgical procedure

• Sex• Male (0) / Female (1)

• Age• </= 64 years old (0)• 65-74 years old (1)• >/= 75 years old (2)

• Comorbidities• Heart Failure (1)• Hypertension (1)• Diabetes Mellitus (1)• h/o Stroke, TIA, or Thromboembolism (2)• Vascular Disease (h/o MI, PAD, aortic atherosclerosis) (1)

HOW TO CALCULATE CHA2DS2-VASC

Stroke Risk:0 points: 0.2% per year1 point : 0.6% per year2 points: 2.2% per year3 points: 3.2% per year4 points: 4.8% per year5 points: 7.2% per year6 points: 9.7% per year

HOW TO CALCULATE HAS-BLED

• H – Hypertension SBP >160 mmHg (1)

• A – Abnormal Renal and Liver Function (1+1)

• S – Stroke (1)

• B – Bleeding Tendency or predisposition (1)

• L – Labile INRs (1)

• E – Elderly (>65 years) (1)

• D – Drugs (ie. ASA, NSAIDs) or excess ETOH (1+1)

HAS-BLED Score0 – 1.131 – 1.022 – 1.883 – 3.744 – 8.7

SHOULD WE ANTICOAGULATE?

• CHA2DS2-VASc score = 4 (4.8% risk)

• HAS-BLED score = 1 (1.02 bleeds per 100 patient-years)

CONCLUSION:Moderate- High risk for thromboembolic events

WithLow risk for bleeding

OPTIONS FOR ANTICOAGULATION

• Warfarin• Goal INR 2.0-3.0• Requires regular monitoring

• Non-vitamin K antagonist oral anticoagulants• Dabigatran aka Pradaxa 150mg bid• Apixaban aka Eliquis 5mg bid OR 2.5mg bid (2 out of 3: age >80yrs, body weight

<60kg, serum creatinine > 1.5mg/dL)• Rivaroxaban aka Xarelto 20mg daily• Edoxaban aka Savaysa 60mg daily OR 30mg daily (CrCl 15-50 mL/minute)

ALTERNATIVES TO ANTICOAGULATION?

• WATCHMAN device• Left atrial appendage occlusion device• Implanted via trans-catheter trans-septal approach• Must tolerate warfarin+ASA for at least 6wks post

implant then Plavix+ASA for additional 6months• Follow up TEE 1-6mths post procedure to assess for

leaks

• Surgical Left Atrial Appendage Ligation• Performed in conjunction with cardiac surgery for

other indications• Follow up TEE post procedure for confirmation of

surgical closure

ARE WE ANTICOAGULATING?

• Journal of American College of Cardiology, May 2017

• Used the PINNACLE Registry to identify 65,000 patients who had non-valvular Atrial Fib and CHA2DS2-VASc Score of >1 between 4/2008 and 9/2014 to examine the effect the availability of direct oral anticoagulants (DOAC) had on overall oral anticoagulant (OAC) use

• Slight increase from 52.4% à 60.7%

• Significant practice-level variation for use OAC ranging from 11-78.8%

• Practices using DOACs ranged from 0-40.4%

• Also found that patients at the highest risk for stroke were the least likely to be treated

• Further research to determine why OACs are not being prescribed to the patients that need them

RATE VS RHYTHM CONTROL

• Rate control

• control of ventricular rate without changing the underlying cardiac rhythm

• Average resting heart rate <80bpm

• Average ambulatory heart rate <100bpm

• Medications:• Beta-Blockers• Metoprolol tartrate 25-100mg BID/Metoprolol succinate 50-400mg daily• Atenolol 25-100mg daily• Carvedilol 3.125mg-25mg BID• Propanolol 10-40mg three to four times daily

• Non-Dihydropyridine Calcium Channel Blockers• Diltiazem 120-360mg daily• Verapamil 120-360mg daily

• Digoxin 0.125-0.375mg daily• Amiodarone 100-200mg daily

RATE VS RHYTHM CONTROL

• Rhythm control

• Presence of symptomatic Atrial Fib despite rate control• Difficulty maintaining rate control• LV dysfunction secondary to Atrial Fib• Patient’s age• Avoid irreversible structural and electrical remodeling with longstanding

persistent Atrial Fib• Need baseline testing to rule out structural heart disease and coronary

artery disease to determine appropriate antiarrhythmic drug

RATE VS RHYTHM CONTROL

• Neither strategy has demonstrated a benefit over the other in regards to:

• Quality of life

• Morbidity

• Mortality

• Rhythm control associated with increased hospitalization rates and treatment costs

UPDATE ON OUR PATIENT

• Echocardiogram• EF 55-60%, normal LV size and dimension• Normal left and right atriums• No structural or valvular abnormalities

• Exercise Stress Test• No evidence of ischemia• Achieved 11.0 METs of activity• Accelerated heart rate response to exercise

• Ambulatory ECG Monitoring – 14 day monitor• Average HR: 84bpm; Heart rate range: 60-180bpm• Atrial Fib burden: 60%• Symptomatic episodes correlated with Atrial Fib with RVR while exercising

Conclusions:1- Poor Heart Rate Control especially with exercise2- Paroxysmal Atrial Fib3- Symptomatic Atrial Fib

WHAT ELSE CAN WE OFFER OUR PATIENT

• Pharmacological• AntiArrhythmics – Class Ic and III agents

• Non Pharmacological• Cardioversion• Ablation• Maze Procedure

PHARMACOLOGICAL

• Class Ic agents:• Flecainide – 50mg BID-150mg BID• Propafenone – 225mg BID-325mg BID

• Class III agents:• Dofetilide – 500mcg BID• ECG monitoring with attention to QT• Monitoring of serum creatinine

• Sotalol – 80mg BID – 160mg BID• ECG monitoring for QTc and PR intervals• Monitor serum creatinine, Mg, K• Monitor HR

• Dronedarone aka Multaq – 400mg daily• ECG monitoring at least every 3mths• Monitor serum electrolytes (K and Mg), liver enzymes and bilirubin

PHARMACOLOGICAL

• Class III agents (cont.):

• Amiodarone

• Dosing: Initiation 400-600mg daily then 100-200mg daily

• Monitor serum electrolytes (K and Mg)

• Assess thyroid function before initiation and every 3-6mths thereafter

• Obtain baseline CXR and PFTs; continue with annual CXR

• Obtain liver function test every 6mths

• Perform regular ophthalmic exams

PHARMACOLOGICAL

• Goals

• reduce the frequency and duration of episodes,

• improve QOL,

• prevent hospitalization

• Antiarrhythmic drugs have potential for serious adverse events

• induction of pro-arrhythmia such as PVCs, monomorphic VT, Torsades de pointes, VF, bradycardia

• Antiarrhythmics may require hospitalization for initiation for monitoring QT interval

NON-PHARMACOLOGICAL

• Electrical Cardioversion• New onset Atrial Fib <48hours in duration or 3-4 weeks of anticoagulation or TEE is

performed prior to assess for left atrial appendage clot

• Atrial Fib Ablation• Catheter based ablation therapy with radiofrequency or cryotherapy most

commonly at the pulmonary veins• Indications: persistent Atrial Fib that has failed on one or more antiarrhythmic

therapy• 20-40% recurrence within 1 year

• MAZE Procedure• Endocardial ablation of atrial tissue performed in the OR as an adjunct to cardiac

surgery for other reasons

PLAN FOR OUR PATIENT

• Start a beta-blocker

• Start an anti-coagulant

• Evaluate patient for sleep apnea

• Re-evaluate patient after initiation of medical therapy

• Referral to cardiology

SUMMARY

• Multiple factors contribute to treatment decisions for atrial fibrillation

• Increasing prevalence most likely due to aging population and increased access to ambulatory ECG monitoring devices

• Anticoagulation therapy is effective in decreasing major risk of stroke, however each patient should be assessed individually to determine risks vs benefit

• Rate control is another top priority in maintaining hemodynamic stability and decreasing long-term complication

• Rhythm control by restoring normal sinus rhythm should be carefully considered and reviewed with each patient

REFERENCES

• Center for Disease Control and Prevention (2017). Atrial Fibrillation Fact Sheet. CDC Online Fact Sheets. Retrieved from: https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm

• January, C.T., Wann, L.S., Apert, J.S., Calkins, H., Cigarroa, J.E., Cleveland, J.C., … Yancy, C.W. (2014) 2014 AHA/ACC/HRS guidelines 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. Circulation, 130, 2071-2104. doi: 10.1161/CIR.0000000000000040

• Lane, D.A, & Lip, G.Y. (2012) Use of the CHAD2DS2-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation, 126, 860-865. doi: 10.1161/CIRCULATIONAHA.111.060061

• Lip, G.Y. (2011). Implications of the CHA(2)DS(2)-VASc and HAS-BLED Scores for thromboprophylaxis in atrial fibrillation. Am J Med, 124(2),111-114.

• Marzen, L.N., Wang, J., Shah, N.D., Chan, P.S., Ting, H.H., Gosch, K.L., Hsu, J.C., & Maddox, T.M. (2017) Influence of Direct Oral Anticoagulants on Rates of Oral Anticoagulation for Atrial Fibrillation. Journal of the American College of Cardiology, 69(20), 2475-2484. doi: 10.1016/j.jacc.2017.03.540