01 dadang how to detect and treat atrial fibrilasi_dr. dadang.pdf
TRANSCRIPT
-
How to detect andtreatATRIALFIBRILLATION
Dr Dadang Hendrawan SpJP(K)
Bagian Kardiologi & Kedokteran VaskulerFK. Unibraw RSU Dr. Saiful Anwar
M A L A N G
-
Atrial Fibrillation
AF is a supraventricular tachyarrhythmiacharacterized by uncoordinated atrial activationwith consequent deterioration of atrialmechanical function ( ACC / AHA / ESC Guideline 2006 )
-
Characteristics of an ECG recordingfor a patient with AF
2
Normal sinus rhythm
Atrial fibrillationTP
R
An ECG of a patient with AF is characterized by disorganized electricalactivity:
1. Consistent P waves are replaced by rapid irregular waves2. Irregular RR intervals
12
Fuster et al, Circulation 2011; Camm et al, Eur Heart J 2010
SQ
P
-
Background
Atrial fibrillation is the most commonsustained arrhythmia
Affects 2 million Americans 6% over the age of 65 experience it Responsible for 15% strokes
Benjamin E: Epidemiology of Atrial Fibrillation. In Falk RH, Podrida PJ, eds:Atrial Fibrillation: Mechanisms and Management.2nd Ed, Lippincott-Raven Press, New York 1997, pp.1-22.
Atrial fibrillation is the most commonsustained arrhythmia
Affects 2 million Americans 6% over the age of 65 experience it Responsible for 15% strokes
Benjamin E: Epidemiology of Atrial Fibrillation. In Falk RH, Podrida PJ, eds:Atrial Fibrillation: Mechanisms and Management.2nd Ed, Lippincott-Raven Press, New York 1997, pp.1-22.
-
Atrial Fibrillation Demographics by Age
U.S. population
Population withatrial fibrillation
U.S. populationx 1000
Population with AFx 1000
30,000
20,000
10,000
0
500
400
300
200
100
0
Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.Age, yr
95
30,000
20,000
10,000
0
500
400
300
200
100
0
-
Atrial fibrillation accountsfor 1/3 of all patient
dischargeswith arrhythmia as
principal diagnosis.
18%Unspecified
6%PSVT
6%PVCs4%
AtrialFlutter
Atrial fibrillation accountsfor 1/3 of all patient
dischargeswith arrhythmia as
principal diagnosis.
2%VF
Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.
34%Atrial
Fibrillation
9%SSS
8%Conduction
Disease
3% SCD
10% VT
-
Classification After 2 or more episodes, AF is considered recurrent AF. If the arrhythmia terminates spontaneously, recurrent AF is
designated paroxysmal AF When sustained beyond 7 d, it is termed persistent AF. The category of persistent AF also includes cases of long-
standing AF (e.g., longer than 1 y), usually leading topermanent AF
Lone AF applies to individuals younger than 60 y withoutclinical or echocardiographic evidence of cardiopulmonarydisease, including hypertension.
After 2 or more episodes, AF is considered recurrent AF. If the arrhythmia terminates spontaneously, recurrent AF is
designated paroxysmal AF When sustained beyond 7 d, it is termed persistent AF. The category of persistent AF also includes cases of long-
standing AF (e.g., longer than 1 y), usually leading topermanent AF
Lone AF applies to individuals younger than 60 y withoutclinical or echocardiographic evidence of cardiopulmonarydisease, including hypertension.
-
AF can be symptomaticand asymptomatic
Typical symptoms of AF include palpitations, fatigue, chest pain, lightheadedness, dyspnoea, syncope1
However, AF may be asymptomatic2 Patients (n=110) with history of AF underwent ECG monitoring with implantable
pacemakerfor 1911 months2
50 patients had AF episodes lasting >48 hours 19 (38%) of these were asymptomatic, with no AF detected by serial ECG
recordingsCumulative incidence of asymptomatic AF recurrence >48 hours not detected by serialECG recordings during follow-up (FU)
Typical symptoms of AF include palpitations, fatigue, chest pain, lightheadedness, dyspnoea, syncope1
However, AF may be asymptomatic2 Patients (n=110) with history of AF underwent ECG monitoring with implantable
pacemakerfor 1911 months2
50 patients had AF episodes lasting >48 hours 19 (38%) of these were asymptomatic, with no AF detected by serial ECG
recordings
1. Fuster et al, Circulation 2011; 2. Israel et al, J Am Coll Cardiol 2004
Baseline FU1 FU2 FU3 FU4 FU5 FU6 FU7 FU8 FU9 FU10 FU11 FU12 FU13
No
of p
atie
nts
110
20
15
10
5
Cumulative incidence of asymptomatic AF recurrence >48 hours not detected by serialECG recordings during follow-up (FU)
-
Prognosis
AF is associated with an increased long-term riskof stroke and HF
The mortality rate of patients with AF is aboutdouble that of patients in normal sinus rhythm andis linked to the severity of underlying heartdisease
One of every 6 strokes occurs in a patient withAF.
AF is associated with an increased long-term riskof stroke and HF
The mortality rate of patients with AF is aboutdouble that of patients in normal sinus rhythm andis linked to the severity of underlying heartdisease
One of every 6 strokes occurs in a patient withAF.
-
Pathophysiology Focal triggering mechanism involving automaticity Multiple reentrant wavelets These mechanisms are not mutually exclusive and may coexist
-
Presentation
History Physical Examination ECG
-
Etiologies and Factors PredisposingPatients to AF
Electrophysiological abnormalities Atrial pressure elevation Atrial ischemia Inflammatory or infiltrative atrial
disease Drugs
Electrophysiological abnormalities Atrial pressure elevation Atrial ischemia Inflammatory or infiltrative atrial
disease Drugs
-
Endocrine disordes Changes in autonomic tone Primary or metastatic disease in or adjacent to
the atrial wall Postoperative Congenital heart disease Neurogenic Idiopathic (lone AF) Familial AF
Etiologies and Factors PredisposingPatients to AF
Endocrine disordes Changes in autonomic tone Primary or metastatic disease in or adjacent to
the atrial wall Postoperative Congenital heart disease Neurogenic Idiopathic (lone AF) Familial AF
-
Minimun evaluation
1. History and physical examination. to define2. Electrocardiogram. to identify3. Transthoracic echocardiogram. to identify4. Blood test of thyroid, renal and hepatic
function
1. History and physical examination. to define2. Electrocardiogram. to identify3. Transthoracic echocardiogram. to identify4. Blood test of thyroid, renal and hepatic
function
-
Additional Testing
One or several tests may be necessary :1. Six-minute walk test2. Exercise testing3. Holter monitoring or event recording4. Transesophageal echocardiograpy5. Electrophysiological study6. Chest radiograph. to evaluate
One or several tests may be necessary :1. Six-minute walk test2. Exercise testing3. Holter monitoring or event recording4. Transesophageal echocardiograpy5. Electrophysiological study6. Chest radiograph. to evaluate
-
MANAGEMENTMANAGEMENT
-
Objectives
Rate Control Prevention of thromboembolism Restoration or maintenance sinus
rhythm
Rate Control Prevention of thromboembolism Restoration or maintenance sinus
rhythm
-
Rate control VS Rhythm control
Two landmark studies published (AFFIRM) and (RACE)trials, found that treating atrial fibrillation (AF) with a rhythmcontrol strategy offers no survival or clinical advantagesover simpler rate control therapy using medications
Two landmark studies published (AFFIRM) and (RACE)trials, found that treating atrial fibrillation (AF) with a rhythmcontrol strategy offers no survival or clinical advantagesover simpler rate control therapy using medications
-
Rate Control
Rate control may be reasonable initial therapy in olderpatients with persistent AF who have hypertension orheart disease
The definition of adequate rate control has beenbased primarily on short-term hemodynamic benefitsand not well studied with respect to regularity orirregularity of the ventricular response to AF, quality oflife, symptoms,or development of cardiomyopathy.
Rate control may be reasonable initial therapy in olderpatients with persistent AF who have hypertension orheart disease
The definition of adequate rate control has beenbased primarily on short-term hemodynamic benefitsand not well studied with respect to regularity orirregularity of the ventricular response to AF, quality oflife, symptoms,or development of cardiomyopathy.
-
Criteria for rate control vary with patient age butusually ventricular rates 60 - 80 beats/m at rest between 90 and 115 beats/m during moderate exercise
Criteria for rate control vary with patient age butusually ventricular rates 60 - 80 beats/m at rest between 90 and 115 beats/m during moderate exercise
-
Rate Control Prevention of thromboembolism Restoration or maintenance sinus
rhythm
Rate Control Prevention of thromboembolism Restoration or maintenance sinus
rhythm
-
20
15
10
5
0
RiskFactor Points
Congestive 1Heart failure
Hypertension 1
Age > 75 1
Diabetes 1
Prior stroke/TIA 2
Key Risk Factors: CHADS2 Score HelpsPredict Stroke Risk in Patients With AF
20
15
10
5
00 1 2 3 4 5
6CHADS2 score
RiskFactor Points
Congestive 1Heart failure
Hypertension 1
Age > 75 1
Diabetes 1
Prior stroke/TIA 2
ACC / AHA / ESC Guideline 2006
-
ACCF/AHA/HRS 2011 and ACCP2008 guidelines: based on CHADS2
CHADS2 scoring1
CHF +1 Hypertension +1 Age 75 years +1 Diabetes mellitus +1 Prior Stroke or TIA +2
CHADS2 scoring1
CHF +1 Hypertension +1 Age 75 years +1 Diabetes mellitus +1 Prior Stroke or TIA +2
1. Gage et al, JAMA 2001; 2. Singer et al, Chest 2008; 3. Fuster et al, Circulation 2011
Recommended therapyCHADS2
scoreACCP20082
ACCF/AHA/HRS20113
0 ASA75325 mg/day
ASA81325 mg/day
1 VKA (INR 23) orASA 75325 mg/day
VKA (INR 23) orASA 81325 mg/day
2 VKA (INR 23) VKA (INR 23)
-
ESC 2010 guidelines: based onCHADS2 and CHA2DS2-VASc
CHF/LV dysfunction +1 Hypertension +1 Age 75 years +2 Diabetes mellitus
+1 Prior Stroke/TIA/TE +2 Vascular disease +1 Age 6574 years
+1 Sex category (female) +1
Initial evaluation: CHADS2 If CHADS2 2 oral anticoagulation If CHADS2
-
VKA limitations
Significant inter- and intra-patient variability in doseresponse1 due to: Co-morbidities Genetic polymorphisms Interactions with food and concomitant drugs Unpredictable pharmacology
Narrow therapeutic window1 Regular coagulation monitoring and dose adjustments
required Increased risk of stroke or bleeding outside the INR range2
Significant inter- and intra-patient variability in doseresponse1 due to: Co-morbidities Genetic polymorphisms Interactions with food and concomitant drugs Unpredictable pharmacology
Narrow therapeutic window1 Regular coagulation monitoring and dose adjustments
required Increased risk of stroke or bleeding outside the INR range2
1. Ansell et al, Chest 2008; 2. Nieuwlaat et al, Am Heart J 2007
-
VKAs have a narrow therapeuticwindow
15
Ischaemicstroke Intracranialbleeding
20
Odd
s ra
tio fo
r eve
nt
Data on bleeding and stroke risk supportrecommendation for narrow INR targetrange
Adjusted odds ratios for ischaemic stroke andintracranial bleeding in relation to intensity of
anticoagulation
28Fuster et al, Circulation 2011
5.0 6.0 8.01.0 2.0 3.0 4.0 7.0
5
10Ischaemic
stroke Intracranialbleeding
1
Odd
s ra
tio fo
r eve
nt
International normalized ratio
-
Rationale for novel oralanticoagulants
Novel oral anticoagulants should fulfill the followingunmet needs: Predictable pharmacology
Target a single coagulation factor Fewer interactions with food or concomitant drugs Can be used at a fixed dose No requirement for routine coagulation monitoring
Improved benefitrisk profile compared with VKAs in patientswith suboptimal INR control
Novel oral anticoagulants should fulfill the followingunmet needs: Predictable pharmacology
Target a single coagulation factor Fewer interactions with food or concomitant drugs Can be used at a fixed dose No requirement for routine coagulation monitoring
Improved benefitrisk profile compared with VKAs in patientswith suboptimal INR control
Bauer, Rev Neurol Dis 2010; Turpie, Eur Heart J 2007; Weitz, Thromb Haemost 2010
-
Newer oral anticoagulants for strokeprevention in AF: clinical trialoverview
Oral anticoagulant Phase II studies Phase III studiesDirect thrombin inhibitorsDabigatran PETRO1 RE-LY2,3
RELY-ABLE4
Direct Factor Xa inhibitorsRivaroxaban ROCKET AF5
J-ROCKET AF6Rivaroxaban ROCKET AF5
J-ROCKET AF6
Apixaban Phase II safety (Japan)7 ARISTOTLE8
AVERROES9
AVERROES-LTOLE10
Edoxaban Phase II dose-finding11
Phase II safety (Asia)12ENGAGE AF-TIMI 4813
Studies in yellow are complete, the others are ongoing1. Ezekowitz et al, Am J Cardiol 2007; 2. Connolly et al, N Engl J Med 2009; 3. Connolly et al, N Engl J Med 2010;4. clinicaltrials.gov, NCT00808067; 5. Patel et al, N Engl J Med 2011; 6. Hori et al, J Thromb Haemost 2011;7. Ogawa et al, Circ J 2011; 8. Granger et al, N Engl J Med 2011; 9. Connolly et al, N Engl J Med 2011;10. clinicaltrials.gov, NCT00496769; 11. Weitz et al, Thromb Haemost 2010; 12. Chung et al, Thromb Haemost 2011;13. Ruff et al, Am Heart J 2010
-
Rivaroxaban20 mg once daily**
N=14,264
ROCKET AF: rivaroxaban vswarfarinRandomized, double-blind, double-dummy, non-inferiority,event-driven trial
Non-valvular AF
History of stroke,TIA or non-CNSSE
OR
2* of the following:
CHF or LVEF35%
Hypertension Age 75 years Diabetes
30-d
ay fo
llow
-up
End
of s
tudy
Warfarin target INR 2.5(23 inclusive)
*Enrolment of patients with
-
ROCKET AF: primary efficacyendpoint
Population/analysis*
No. ofpatients
Rivaroxaban(% per year)
Warfarin(% peryear)
Hazardratio
(95% CI)
p-valueNon-
inferiority SuperiorityPer-protocol,on-treatment
6958 1.7 2.2 0.79(0.660.96)
-
Summary
Control the rate Decide whether NOT to anticoagulate Consider referral for antiarrhythmic or non
pharmacological treatment