atrial fibrillation: why is it so important in clinical ... · ashish nabar mumbai. af: clinical...

Atrial fibrillation:

Why is it so Important in

Clinical Practice?

Ashish Nabar

Mumbai

AF: CLINICAL IMPORTANCE!AF: FAST, IRREGULAR, AV DYSSYNCHRONY

Atrial fibrillation:Clinical Importance

• Control of symptoms

• Prevention of stroke

(thrombo-embolism)

• Prevention of tachycardia-

induced cardiomyopathy

• Improved survival

I. PHARMACOVERSION OF SYMPTOMATIC ACUTE AF

• ED CARDIOVERSION FOR AF F/B

DISCHARGE IN SR: SAVES

HOSPITALIZATION COSTS

• PHARMACOVERSION LESS RESOURCE

INTENSIVE (PROCEDURAL SEDATION)

• AMIODARONE: HOURS,

IBUTILIDE, VERNAKALANT: MINS

ACUTE AF CONVERSION: CONSIDER IBUTILIDE

ACUTE AF CONVERSION: VERNAKALANT

EARLY CONVERSION SAFE CONVERSION

ATRIAL FIBRILLATION: MAINTAINING SINUS RHYTHM

II. AF is a Thromboembolic Risk!!

5-FOLD Increase STROKE risk

3-FOLD Increase HF risk

2-FOLD Increase DEMENTIA and MORTALITY

Multiple HOSPITALIZATIONS

AF:

Preventing thrombo-embolism

Even under rhythm

control strategy,

probably due to

asymptomatic AF

episodes, stroke risk

continues to be present

and appropriate anti-

thrombotic therapy must

be continued.

ASPIRIN is NOT EFFECTIVE

FOR STROKE PREVENTION in

pts with AF and in fact, may

increase the risk of stroke in

elderly pts, so it is therefore no

longer recommended for this

purpose.

NVAF & Stroke Prevention:

Risk score decides, not the clinical type!

NVAF & Stroke Prevention:

Weigh the Bleeding risk

HAS-BLED Scoring system

VKA: 60 years of use!Yet under-prescribed, barrier to stroke prevention

Average TTR = 63%

Stroke & Mortality risk

decreased if TTR >70%

AF & Stroke Prevention: NOAC

NOACs are non inferior to Warfarin

to prevent stroke and systemic embolic events

Superior safety compared to Warfarin

less ICH

however, slightly increased risk of GI bleeding

Versatile use

No laboratory monitoring

Limitations

Dose adjustments, if CKD

AF with other cardiovascular conditions, must await trial

results

Limited availability of reversal agent

AF & Stroke Prevention: NOACs

NOAC for NVAF following PCI:

Figure 1. AF and heart failure (HF): a vicious pathophysiological cycle.

III. AF & HF: A 2-way relation!

AF: Risk Factor for HF or Marker of Advanced HF?

• Large HF trials (SOLVD, VALIANT, COMET)

– Baseline AF is a negative prognostic marker

• All cause mortality, Progressive pump failure and combined

end point of death or HF hospitalization increases

– New onset AF carries a poorer prognosis (80%

mortality) than no / persistent AF (60-65%)

• Clinical and hemodynamic worsening, risk of systemic TE,

inadequate rate control

AF in HF: How best to treat?Intuitively Rhythm Control!

• Pharmacotherapy:

– Amiodarone, Sotalol, and Dofetilide: Conditionally safe

– Never use of Class I AADs: Risk of TdP

• Amiodarone:

– Safe and effective

– risk for symptomatic bradycardia

• Sotalol:

– For mild LV systolic dysfunction

Rhythm Controlling AF:Electrical Cardioversion: Don’t be SHY!

• Pharmacotherapy unlikely to convert AF >48 hours

duration

• Preferred as a test / term solution:

– New onset AF, LA size <45mm, Hemodynamically

compromised patient

• Avoided:

– Long standing AF, Large LA, Severe SHD

AF in HF: Ventricular Rate ControlIs it really Next Best!

• Optimal VR control:

– Resting HR: 60 to 80 bpm

– Moderate exertion: 90 to 115 bpm

– 24-hour Holter assessment

• Beta-Blockers :

– first choice: improves survival, controls VR

• Digoxin:

– Synergistic with BB

• Avoid CCB (Verapamil, Diltiazem): except in MS

Rate Control Intervention inAF:Ablation and Pacemaker Therapy

Pre-excited AF: Survival st Stake!

FBI: Pre-excited atrial fibrillation