atrial fibrillation 2018: controversy and consensus · from: 2014 aha/acc/hrs guideline for the...

Atrial Fibrillation 2018:

Controversy and Consensus

Eric N. Prystowsky, MD

Conflict of Interest

• Consultant: Medtronic ; CardioNet

• Institutional Fellowship support:

Medtronic; St Jude

Estimated Probability of Appropriate ICD Therapy

(Primary Prevention) as a Function of Post CRT-D LVEF

From: Manfredi Circulation AE 2013;6:257-264

Overview of Management of Atrial Fibrillation

From: Prystowsky EN JAMA 2015, 314: 278-288

Treatment Strategy for Atrial

Fibrillation

Rate versus Rhythm

Screened

N = 7401

Withdrew

n = 71

Enrolled

N = 4060Status Unknown

n = 26

Follow-up

N = 3963

Declined

n = 3341(45%)

AFFIRM Investigators NEJM 2002; 347:1825-33

AFFIRMEnrollment

Rate Versus Rhythm Control in Patients with

A. Fib (AFFIRM)

From: AFFIRM investigators NEJM 2002; 347:1825

“Documented” Safety of

Persistent Atrial Fibrillation

AGE

0 62 72 100

“From Stettin in the Baltic to Trieste in the Adriatic,

an iron curtain has descended across the continent.”~ Churchill, March 5, 1946

“From Honolulu in the Pacific to Athens in the Aegean,

the AFFIRM mismessage curtain has descended

across Western medicine.”

If there was a safe and effective

method to restore and maintain

sinus rhythm, would you allow

your patient to remain in atrial

fibrillation?

Quebec, Canada

Population-based Study

of Patients with AF

From: Ionescu-Ittu R et al. Arch Intern Med

2012; 172: 997

Effect on Rhythm vs. Rate Control Therapy

on Mortality Over Time

From: Ionescu-Ittu R et al. Arch Intern Med 2012; 172: 997

Long-term Outcomes in Patients With AF; AF/RFA;

No AF History

From: Bunch TJ et al. J Cardiovasc Electrophysiol 2011; 22:

839

Cognitive Function Evaluation in Controls (green),

Paroxysmal AF (blue) and Persistent AF (red)

From: Gaita et al., JACC 2013; 21: 1990-7

Salutary Effects of Sinus Rhythm on Heart Failure

• Regularization of rhythm

• Physiologic rate control

• Atrial contirbution to cardiac output

Death from Cardiovascular Causes (AF-CHF Trial)

From: Roy D et al. N Engl J Med 2008; 358:

2667-2677

Rhythm Control vs. Rate Control for Atrial Fibrillation and

Heart Failure

From: Roy D et al. N Engl J Med 2008; 358:

2667-2677

From: Hsu L et al. NEJM 2004; 351: 2373-83

Improvement in Left Ventricular Function After Ablation of

Atrial Fibrillation in Patients with Congestive Heart Failure

Patient T.H.

HPI: A 44 y/o man is referred for consideration of CRT

device. He has NIDCM with an LVEF 0.10, NYHA-III

heart failure symptoms, and MDT ICD with MVP.

He has A. Fib with controlled ventricular response.

PE: HR 82/min, irreg; BP 130/60

Lungs - clear

Heart - no S3; no murmur

ECG: A. Fib, rate 84; LBBB; QRS 171 msec

Meds: Carvedilol 25 mg bid; lanoxin 0.125/qd; warfarin;

lisinopril 20 mg qd; diltiazem 60 mg tid

Patient T.H.

• TEE-cardioversion to SR

6 months later:

• ICD: AAIR DDDR 70-120: Ap 95%; Vp 0.4%;

No VT Rx

• ECG: A paced 76/min; LBBB

• ECHO: LVEF 15-20%

• NYHA-I heart failure symptoms

Sinus Rhythm: A bridge to the

future

Patient case

• A 60 year old man with 2 years of AF saw me

for a second opinion. Initial CV resulted in

IRAF. He has been in persistent AF with rate

control, and thinks he feels “ok”. Amiodarone

was started and cardioversion was

associated with sinus rhythm and he now

feels “ great with increased energy”.

Treatment Strategy for Atrial Fibrillation: Rate vs Rhythm

A continuing Controversy

Proposed Treatment Algorithm for Paroxysmal and Persistent Atrial Fibrillation


Drugs versus Ablation

From: 2014 AHA/ACC/HRS Guideline for the Management of

Patients with Atrial Fibrillation, Circulation, March 28, 2014

Strategies for Rhythm Control in Patients

with Paroxysmal and Persistent AF

Radiofrequency Catheter Ablation to Isolate the Pulmonary Veins and

Rotor Mapping and Ablation


Paroxysmal A. Fib: seconds/minutes

Ablation

approach:

Triggers

Normal Atria

Persistent A. Fib

Ablation

approach:

Substrate

and TriggersAbnormal Atria

(Fibrosis)

Single Procedure Success for Paroxysmal AFRandomized Controlled Trials

Dukkipati, J Am Coll Cardiol. 2015;66:1350-1360

Results spectacular in some patients, dismal in others

Goals of rhythm control

• It is not necessary to eliminate all

episodes of AF

• Minimize frequency and duration of AF

episodes (atrial burden)

• Let the patient be your guide

Rate Control



Summary of Selected Recommendations for Rate Control

Recommendations

Control ventricular rate using a beta blocker or

nondihydropyridine calcium channel antagonist for

paroxysmal, persistent, or permanent AF.

For AF, assess heart rate control during exertion, adjusting

pharmacological treatment as necessary

A heart rate control (resting heart rate < 80 bpm) strategy

is reasonable for symptomatic management of AF

Lenient rate control strategy (resting heart rate < 110 bpm)

may be reasonable with asymptomatic patients and LV

systolic function is preserved.

COR

I

I

IIa

IIb

LOE

B

C

B

B

H.B. 8/05

Treatment Strategy for Atrial

Fibrillation: Prevention of Stroke

Mostly Consensus

From: 2014 AHA/ACC/HRS Guideline for

the Management of Patients with Atrial

Fibrillation, Circulation, March 28, 2014

Coagulation Cascade

Limitations of warfarin therapy

• Routine coagulation monitoring

• Frequent dose adjustments

• Difficulty maintaining stable TTR

• Numerous food-drug interactions

• Numerous drug-drug interactions

Primary Outcome of Stroke or Systemic Embolism in (RE-LY)

From: Connolly SJ et al. NEJM August 2009

Stroke or Systemic Embolism in ROCKET AF

From Patel MK et al. NEJM 2011; 365: 883-91

p < 0.001 for noninferiority

Primary and Safety Outcomes in ARISTOTLE (Apixaban

in A. Fib)

From: Granger CB et al. NEJM 2011; 365:

981-92

Edoxaban vs. Warfarin in Patients with AF ENGAGE-AF

From: Giugliano RP NEJM 2013; 69: 2093-104

Limitations of DOACs

• Expensive

• Avoid use in severe renal disease

• Minimal data in very elderly

• Avoid in certain types of valvular HD

• Use in new onset Afib cardioversion

without TEE requires more data

NOAC vs warfarin: My approach

• Have an in-depth discussion with the

patient concerning the risks/benefits of

various AC approaches

• For the patient who is taking warfarin and

has had stable TTRs and prefers not to

change: Leave well enough alone

• For patients just starting AC who have no

reason to avoid a NOAC: prescribe a

NOAC



Summary of Selected Recommendations for Prevention of

Thromboembolism in Patients with AF

Recommendations

Antithrombotic therapy based on shared decision-making,

discussion of risk of stroke and bleeding, and patient’s

preferences

CHA2DS2-VASc score recommended to assess stroke risk

With prior stroke, TIA, or CHA2DS2-VASc score >2,

oral anticoagulants recommended. Options include:

- Warfarin

- Dabigatran, rivaroxaban, or apixaban

With warfarin, determine INR at least weekly during

initiation and monthly when stable

COR

I

I

I

I

I

LOE

C

B

A

B

A




Thromboembolism in Patients with AF

Recommendations

With nonvalvular AF and CHA2DS2-VASc score of 0, it is

reasonable to omit antithrombotic therapy

With nonvalvular AF and a CHA2DS2-VASc score of 1,

no antithrombotic therapy or treatment with an oral

anticoagulant or aspirin may be considered.

For PCI, BMS may be considered to minimize duration of

DAPT

Following coronary revascularization in patients with

CHA2DS2-VASc score of >2, it may be reasonable to use

clopidogrel concurrently with oral anticoagulants, but

without aspirin.

COR

IIa

IIb

IIb

IIb

LOE

B

C

C

B

Cardioversion of AFTEE Guidance: ACUTE Study Protocol

Klein et al. N Engl J Med. 2001;344:1411-1420.

4 weeks warfarin

Follow-upexamination

AF > 2 days’ duration

Therapeutic A/C at time of TEE

No thrombus

4 weeks warfarin

Repeat TEE

Thrombus persistsNo cardioversion

3 weeks warfarin

Cardioversion

4 weeks warfarin

TEE-guided group n=619 Conventional therapygroup n=603

LA or LAAThrombus detected

4 weeks warfarin

Thrombus resolvedCardioversion

4 weeks warfarin




Thromboembolism with Cardioversion of AF and A Flutter

Recommendations

With AF or atrial flutter for >48 h, or unknown duration,

anticoagulate with warfarin for at least 3 wk prior to and

4 wk after cardioversion

With AF or atrial flutter for >48 h or unknown duration

requiring immediate cardioversion, anticoagulate as soon

as possible and continue for at least 4 wk.

With AF or atrial flutter for <48 h and high stroke risk,

IV heparin or LMWH or factor Xa or direct thrombin

inhibitor, is recommended before or immediately after

cardioversion, followed by long-term anticoagulation.

Following cardioversion of AF, long-term anticoagulation

should be based on thromboembolic risk.

COR

I

I

I

I

LOE

B

C

C

C




Thromboembolism with Cardioversion of AF and A Flutter

Recommendations

With AF or atrial flutter, for >48 h or unknown duration and

no anticoagulation for preceding 3 wk, it is reasonable to

perform a TEE prior to cardioversion, and then cardiovert

if no LA thrombus is identified, provided anticoagulation is

achieved before TEE and maintained after cardioversion

for at least 4 wk.

With AF or atrial flutter >48 h or unknown duration,

anticoagulation with dabigitran, rivaroxiban, or apixaban is

reasonable for >3 wk prior to and 4 wk after cardioversion.

With AF or atrial flutter <48 h and low thromboembolic risk,

IV heparin, LMWH, a new oral anticoagulant, or no

antithrombotic may be considered for cardioversion.

COR

IIa

IIa

IIb

LOE

B

C

C

Stroke prevention in “silent

AF”: unanswered questions

Use of ECG Monitoring to Detect AF in Patients after

Cryptogenic Stroke (EMBRACE)

• 572 patients after cryptogenic stroke randomized to

30-day event recorder versus 24-hour Holter monitor

• Event monitor (Braemar) with autodetect AF capability

(over a period of 30 beats)

• Mean age 72 years

• Randomization mean of 75 days after stroke

• 82% of monitored patients completed > 3 weeks

From: Gladstone DJ NEJM 2014; 370: 2467-77

Atrial Fibrillation Detected During Prolonged Ambulatory

Monitoring in Patients with Cryptogenic Stroke (EMBRACE)

From: Gladstone DJ NEJM 2014; 370: 2467-77

Atrial Fibrillation Detected by Implantable Cardiac Monitor in

Patients With Cryptogenic Stroke (CRYSTAL AF)

From: Sanna NEJM 2014; 370: 2478-86

Mass Screening for Atrial Fibrillation (STROKESTOP Study)

• Ongoing study to determine the value of AF screening

in 75-year-old persons and anticoagulant therapy to

reduce stroke over 5 years follow-up

• Monitoring with handheld ECG recorder (Zenicor)

• 30-second ECG rhythm strips twice daily for 2 weeks

and with palpitations

• New AF detected in 218 (3%) of patients

From: Svennberg E Circulation 2015; 131: 2176-84

Time to First Detection of Atrial Fibrillation

From: Svennberg E Circulation 2015; 131: 2176-84

Patient P-85

HPI: A 88-year-old woman was sent for an electrophysiology

consult because her PCP felt an irregular pulse at a

routine exam. The patient has no cardiac symptoms.

PMH: Hypertension

PE: HR 87 with ectopy; BP 140/90;

Lungs – clear; Heart: ectopy; No m

Ext: +1 bilateral pedal edema

ECG: Sinus rhythm with PACs

Patient P-85

Holter: 984 PACs; several runs of relatively rapid AT-NS

ECHO: LVEF 55-60%

LA 3.9 cm

No LVH

Effect of

Excessive

Supraventricular

Ectopic Activity

(ESVEA) on

Stroke Risk

From: Larsen et al. J Am Coll

Cardiol 2015; 66: 232-41

atrial fibrillation 2018: controversy and consensus · from: 2014 aha/acc/hrs guideline for the...

Documents