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Cardiology for the Non-Cardiologist 2018

George (“Yorgo”) Veenhuyzen MD

Associate Professor

Electrophysiology Training Program Director

Libin Cardiovascular Institute of Alberta

University of Calgary


Cardiology for the Non-Cardiologist

Faculty: Veenhuyzen

Relationships with Financial Sponsors:

- Grants or Research Support:

- Speakers Honoraria: BMS-Pfizer, Servier, Medtronic

- Consulting Fees: Servier, Abbott, Boehringer-Ingelheim

- Patents:

- Other:


Cardiology for the Non-Cardiologist has received financial support from the following Pharmaceutical companies; Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.

Potential Conflicts of Interest:

1. Most lucrative thing I do is catheter ablation

2. I’ve received honoraria and/or consulting fees from manufacturers of all NOACs and ablation catheters


• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.


• 1) What hasn’t changed since 2016

• 2) What’s new since 2016

• 3) What I’m excited about in the future


78 yo female; 74 kg; Intermittent mild palpitation. HTN on ACE-i. Remote

PUD bleed. CrCl 52. Hg & TSH normal. Echo: mild LVH, LA dilatation,

moderate to severe MR. Fatigued on Bisoprolol. Asymptomatic on

Verapamil (tolerable ankle edema).


1. No OAC: bleed risk too high; use ASA instead

2. Warfarin INR 2-3: she has valvular AF, only warfarin OAC should be used

3. Low dose Non Vit K dependant OAC (NOAC): she’s elderly

4. Full dose NOAC: no need for reduction


BAFTA Lancet 2007;270:493-503

•Mean age = 81.5 yr (SD 4.2)

•260 primary care offices with AF, Aflutter

•Excluded: ICH, GI bleed in 1 yr, major bleed in 5

years, varices, terminal illness, BP > 180/110

ASA 75 mg/d

INR 2-3

Str

oke:

hem

orr

hagic

or

thro

mbotic,

& S

E

NNT=50/y


BAFTA Lancet 2007;270:493-503

NNH=0/y


NNT=47/y

AVERROES Trial


NNH=0/y

AVERROES Trial


1. Rhythm control with Sotalol, Propafenone, or

Amiodarone

2. Continue present management

3. Pacemaker & AVN ablation

4. Catheter ablation (Pulmonary Vein Isolation)


Complication Rate: 9.1%

Hematoma 2.3%

Pseudoaneurysm 1.1%

Tamponade 0.8%

Pericarditis 1.1%

Esophageal Ulcer 0.5%

No deaths or strokes


Complication Rate: 4.1%

Thyroid 1.6%

VT/VF 0.8%

Liver 0.3%

Pulmonary 0.1%

No deaths


54 yo long distance runner.

Resting sinus rate 46 bpm.

Normal echo and TSH.


1. VVI pacemaker + flecainide/betablocker

2. DDD pacemaker + amiodarone

3. VVI pacemaker + diltiazem

4. DDD pacemaker + digoxin

5. No pacemaker: catheter ablation (PVI)


• 64 yo lady; prior inferolateral MI; EF 0.28; prophylactic ICD; OMT for CHF; no palpitation; NYHA II-III dyspnea; NOAC


1. Upgrade to CRT and AVN ablation

2. Add ivabridine

3. Refer for AF ablation

4. Add amiodarone and cardiovert

5. Continue present management


• Symptomatic AF

• Failed by AADs

• LVEF < 36%

• ICD


• EF < 45%; NYHA II-III; Elevated nt-BNP

• Rate control VS

• Catheter Ablation

• N=1000 patients (enrollment stopped at 400)

• Outcome: Death and CHF Hospitalization (extended f/u)


Auricchio et al JACC-EP 2017


JACC 2018

10.1016/j.jacc.2018.02.048


Elective or ACS PCI

Rivarox 15 + P2Y12i

Rivarox 2.5BID + DAPT

Warfarin+ DAPT

Dabigatran 110 + P2Y12i

Dabigatran 150 + P2Y12i

Warfarin+ DAPT

Pioneer AF-PCI

n=2124

RE-DUAL PCI

n=2725


Apixaban 5 + P2Y12i

Apixaban 5 + P2Y12i + ASA

Warfarin + P2Y12i

Warfarin + P2Y12i + ASA

Elective or ACS PCI

AUGUSTUSURL: https://clinicaltrials.gov/ct2/show/NCT02415400


• OCEAN: • ASA 81 mg vs Rivaroxaban 15 mg after successful ablation for AF• SSE

• BRAIN AF: • ASA 100 mg vs Rivaroxaban 15 mg in low risk AF patients• Stroke/TIA/Neurocognition

• ARTESiA: • ASA 81 mg vs Apixaban in SCAF < 24 hrs.; CHADSVASc >1• SSE/Bleeding

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