Atrial Fibrillation - From Diagnosis to Treatment

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Information about Atrial Fibrillation - From Diagnosis to Treatment
Health & Medicine

Published on March 6, 2014

Author: JoseOsorio16

Source: slideshare.net

Description

CME Lecture for the medical staff at St Vincent's Hospital.

Atrial fibrillation is a common rhythm disorder. There are many treatment options available today.

Jose Osorio, MD www.theafcenter.com

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Atrial Fibrillation Demographics by Age U.S. population x 1000 Population with AF x 1000 Population with atrial fibrillation 30,000 500 400 U.S. population 20,000 300 200 10,000 100 0 0 <5 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 90- >95 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 94 Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473. Age, yr www.theafcenter.com

5 4.78 5.16 5.42 5.61 4.34 4 3.80 3 2 2.08 2.26 2.44 2.66 2.94 3.33 1 20 60 20 50 20 45 20 40 20 35 20 30 20 25 20 20 20 15 20 10 20 05 20 00 0 19 95 Adults with AF, MM 6 Year Go A, et al. JAMA. 2001;285:2370-2375. www.theafcenter.com

Atrial Fibrillation Costs to the health care system A LOT!! Average hospital stay = 5 days Mean cost of hospitalization = $18,800 Does not include: Costs of cardioversions/ablations/surgery Costs of drugs/side effects/monitoring Costs of AF-induced strokes Estimated US cost burden 15.7 billion www.theafcenter.com

First Detected Paroxysmal (Self-terminating) Persistent (Not self-terminating) Permanent www.theafcenter.com

 Paroxysmal ◦ few seconds to days, then stops on its own ◦ Typically younger, healthier patients  Healthier “Lone Afib” Persistent ◦ does not stop by itself but will stop with a medication or cardioversion  Permanent ◦ present all the time and cannot be fixed with medication or cardioversion More Comorbidities

• Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com

   Thyroid Disease. Alcohol Consumption. Cardiac Surgery.       15% to 33% of CABG patients 38% to 64% of valve surgery. Valvular Disease. Heart Failure. WPW Hypertension/LVH www.theafcenter.com

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Atrial Fibrillation Obstructive Sleep Apnea 20 – 15 – OSA Cumulative 10 – Frequency of AF (%) 5– No OSA 0– 0 1 2 3 4 5 6 No OSA 8 9 10 11 12 13 14 15 Years Number at Risk OSA 7 844 709 569 478 397 333 273 214 173 134 110 94 70 46 29 8 2,209 1,902 1,616 1,317 1,037 848 641 502 393 296 217 195 130 94 69 28 Cumulative frequency curves for incident atrial fibrillation (AF) for subjects < 65 years of age with and without obstructive sleep apnea (OSA) during an average 4.7 years of follow-up. p = 0.002 Gami, et al. JACC 2007;49:565-71 www.theafcenter.com

• Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com

Atrial Fibrillation and Strokes • 5-fold higher risk of stroke • Over 87% of strokes are thromboembolic • >90% of thrombus originates in the Left Atrial Appendage (LAA) • Stroke is the number one cause of long-term disability and the third leading cause of death in patients with AF www.theafcenter.com

• 500,000 strokes/year in U.S. • Up to 20% of ischemic strokes occur in patients with atrial fibrillation Percent of Total Strokes Attributable to Atrial Fibrillation 35 30 25 20 % 15 10 5 0 50-59 60-69 Stroke 22(18), 1991 70-79 80-89 3000838-7 www.theafcenter.com

 >90% of strokes in AF patients are secondary to LAA emboli www.theafcenter.com

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Cardiac failure Hypertension Age >75 Diabetes Stroke – 2 points Limitation CHADS2 of 0 or 1 patients may still have a moderate risk for stroke www.theafcenter.com

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Atrial Fibrillation Stroke Prophylaxis www.theafcenter.com

Atrial Fibrillation Challenges in Stroke Prevention • Warfarin • Not always well-tolerated • Less than 50% of patients eligible are being • Time at therapeutic range - low • Prevent Ischemic Strokes  Cause Hemorrhagic Strokes www.theafcenter.com

• Warfarin still cornerstone of therapy • Assuming 51 ischemic strokes/1000 pt-yr • Warfarin prevented 28 strokes at expense of 11 fatal bleeds • Aspirin prevented 16 strokes at expense of 6 fatal bleeds • Warfarin • 60-70% risk reduction vs no treatment • 30-40% risk reduction vs aspirin Cooper: Arch Int Med 166, 2006 Lip: Thromb Res 118, 2006 3000838-10 www.theafcenter.com

Low INR <1.6 Efficacy 4-fold Therapeutic INR 2-3 High INR >3.2 0 20 40 60 80 100 % Bungard: Pharmacotherapy 20:1060, 2001 3000838-14 www.theafcenter.com

 Novel Anticoagulants ◦ Pradaxa – Dabigatran ◦ Xarelto – Rivaroxaban ◦ Eliquis – Apixaban www.theafcenter.com

 Contraindications for anticoagulants: ◦ ◦ ◦ ◦ ◦ Bleeding Hemorrhagic Stroke Frequent Falls Low Platelet Count Recent Surgery Patient’s choice www.theafcenter.com

  What can we offer patients that cannot take oral anticoagulants? Or do not want to take OACs ◦ Left Atrial Appendage Closure www.theafcenter.com

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Pericardial Access www.theafcenter.com

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3000838-18 www.theafcenter.com

Device Day 0 Day 2-14 Preimplant interval Day 45 postimplant Device subject takes warfarin Ongoing to 5 years Device subject has ceased warfarin Control Device subject gets implant Randomize Control subject takes warfarin Day 0 Ongoing to 5 years 3000838-60 www.theafcenter.com

• Primary Efficacy Endpoint • All stroke: ischemic or hemorrhagic • deficit with symptoms persisting more than 24 hours • • or • symptoms less than 24 hours confirmed by CT or MRI Cardiovascular and unexplained death: includes sudden death, MI, CVA, cardiac arrhythmia and heart failure Systemic embolization www.theafcenter.com

Baseline Risk Factors WATCHMAN N= 463 Control N= 244 P-value 1 158/463 (34.1) 66/244 (27.0) 0.3662 2 157/463 (33.9) 88/244 (36.1) 3 88/463 (19.0) 51/244 (20.9) 4 37/463 (8.0) 24/244 (9.8) 5 19/463 (4.1) 10/244 (4.1) 6 4/463 (0.9) 5/244 (2.0) Paroxysmal 200/463 (43.2) 99/244 (40.6) Persistent 97/463 (21.0) 50/244 (20.5) Permanent 160/463 (34.6) 93/244 (38.1) 6/463 (1.3) 2/244 (0.8) 57.3 ± 9.7 56.7 ± 10.1 460 (30.0, 82.0) 239 (30.0, 86.0) CHADS2 Score AF Pattern Unknown LVEF % 0.7623 0.4246 www.theafcenter.com

Randomization allocation (2 device : 1 control) Device Cohort 900 pt-yr Posterior Probabilities Control Events (no.) Total pt-yr Rate (95% CI) Events (no.) Total pt-yr Rate (95% CI) Rel. Risk (95% CI) Noninferiority Superiority 20 582.3 3.4 (2.1, 5.2) 16 318.0 5.0 (2.8, 7.6) 0.68 (0.37, 1.41) 0.998 0.837 Event-free probability 1.0 ITT Cohort: Non-inferiority criteria met WATCHMAN 0.9 Control 0.8 0 365 730 1,095 52 92 12 22 Days 244 463 147 270 3001664-2 www.theafcenter.com

  Oral Anticoagulation is still considered first line therapy Lariat Device ◦ Reserved for patients with Contraindications to oral anticoagulants  Watchman device ◦ Great results in patients that were eligible to take warfarin ◦ May become first line therapy www.theafcenter.com

 What if my patient is back to Sinus Rhythm?  Does he still need anticoagulation?  What about after cardioversion? www.theafcenter.com

30 Rate Rhythm 25 Mortality, % 20 p=0.078 unadjusted 15 p=0.068 adjusted 10 5 0 0 1 2 3 Rhythm N: 2033 1932 Time (years) 1807 1316 Rate N: 2027 1925 1825 1328 4 5 780 255 774 236 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. www.theafcenter.com

Rate Rhythm Ischemic stroke 77 (5.5%)* 80 (7.1%)* INR < 2.0 27 (35%) 17 (21%) Not taking warfarin 25 (32%) 44 (55%) * p=0.79 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. www.theafcenter.com

  AFFIRM has demonstrated that rate control is an acceptable primary therapy in a selected high-risk subgroup of AF patients with minimal symptoms Discontinuation of OAC in patients with risk factors for stroke after CV or while on rhythm control drugs is not appropriate ◦ Asymptomatic recurrences www.theafcenter.com

• Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com

ANTITHROMBOTIC RX AND RHYTHM CONTROL OR ? RATE CONTROL www.theafcenter.com

ANTITHROMBOTIC RX AND RHYTHM CONTROL Greater AF Symptoms OR ? RATE CONTROL Minimal or no symptoms www.theafcenter.com

Atrial Fibrillation Treatment Options • Rate Control • Rhythm Control • Medications • Cardioversion • Ablation www.theafcenter.com

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74 yo medically refractory AF, Echo – Normal AA Rx - Verapamil, Rythmol, Betapace, Norpace I II III V1 RSPV dist RSPV prox * LIPV RA www.theafcenter.com

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Atrial Fibrillation Afib Triggers www.theafcenter.com

Atrial Fibrillation Afib Triggers www.theafcenter.com

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Radiofrequency Ablation Cryoablation www.theafcenter.com

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1. Access targeted vein 2. Inflate and position 3. Occlude and ablate 4. Assess PVI 60 60 www.theafcenter.com

Delay Increased Delay Isolation Images: Courtesy of Dr. Schwagten, ZNA Middelheim, Belgium (above) and Dr. Vogt, Herz- und Diabeteszentrum NRW, Germany (right) www.theafcenter.com

Lasso Guided PV Isolation Before Ablation During Ablation A PV A PV After Ablation I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1 100 ms A www.theafcenter.com

Pappone C, et,al.J Am Coll Cardiol. 2006 Dec 5;48(11):2340-7. www.theafcenter.com

Freedom from AF Recurrence P<0.001 Pappone C, J Am Coll Cardiol 2003 www.theafcenter.com

QOL Following Ablation vs. Medical Therapy for AF Pappone C, et.al. JACC 42:185-97, 2003 www.theafcenter.com

LV Function after AF Ablation Patients with of Without CHF Hsu LF, et.al., NEJM 351:2372-83, 2004 www.theafcenter.com

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CRYO Procedure Experience Impacts Treatment Success P < 0.001 by quartile (Wald) OR = 1.14 for each procedure Treatment Success 100% 90% 69% 66% 80% 56% 60% 40% 20% 0% 25 centers n=43 1st and 2nd procedures 14 centers n=38 3rd – 5th procedures 10 centers n=42 6th – 11th procedures 4 centers n=40 12th – 23rd procedures 69 www.theafcenter.com

 Candidates for ablation ◦ Symptomatic atrial fibrillation despite medical therapy  Paroxysmal Afib  easy to determine  Persistent Afib  Symptoms related to Afib?  Structural Heart Disease / LA dimension  Comorbidities www.theafcenter.com

 AF is rarely life-threatening and is typically recurrent  Treatment goals in symptomatic pts ◦ frequency, duration and severity of recurrences ◦ Reduce Stroke Risk ◦ Minimize risk of tachycardia induced cardiomyopathy www.theafcenter.com

Atrial Fibrillation   Highly Prevalent Condition Treatment ◦ driven by symptoms  Atrial fibrillation ablation ◦ ◦ ◦ ◦   Effective Reduces or eliminates symptoms Reduces risk of stroke Significantly improves quality of life www.theafcenter.com 205-939-0073 www.theafcenter.com

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