atrial fibrillation nora goldschlager, m.d. macp, facc, faha, fhrs cardiology – san francisco...

ATRIAL FIBRILLATION

Nora Goldschlager, M.D.MACP, FACC, FAHA, FHRS

Cardiology – San Francisco General HospitalUCSF

Disclosures: None

INCREASING PREVALENCE OF AF

2005 2015 2025 2035 2045

Naccarelli et al AJC 2009;104:15334Reuters database, US Census Bureau Projected Estimates

Year

Ind

ivid

ual

s w

ith

AF

on

ly(m

illio

ns)

8

6

4

2

0

All

Men

Women

INCIDENCE

• Occurs in ≥ 2% of population(more than 5 million pts in US;

projected >10 million by 2050)• Prevalence increases with age

1% in people > 60 5 - 6% of people > 6514% of people > 80

• Associated with > 100,000 strokes / yr• Develops in 10 - 30% of pts with

LV dysfunction; is a predictor of mortality (1 - 3x)

• RR for death 1.5 (men) and 1.9 (women)

CONSEQUENCES OF AF IN THE US:US DATABASE ANALYSIS

350,000 hospitalizations/yr7 million office visits/yr542,000 ED visits/yr$6.42 billion annually

Coyne et al Circulation 2004; 110:III - 826Zimetbaum, Circulation 2005; 111:3141

Types

• Paroxysmal – Self-terminating• Persistent – Requires cardioversion

to restore sinus rhythm• Permanent – Complete inability to

maintain sinus rhythmEtiologies

• Rheumatic• Nonrheumatic• Lone

CLASSIFICATION

ASYMPTOMATIC ATRIAL FIBRILLATION

• Incidence 20 - 50%

• Most asymptomatic pts have chronic AF

• Up to 50% of pts with paroxysmal AF have no symptoms (pacemaker stored data)

• Occurs in up to 20% of pts with no AF history (ICD stored data)

• Is present in up to 30% of pts presenting with stroke without AF history

Risk of AF in systolic dysfunction

• Men 4.5x• Women 5.9x• Whites 38%• AA 20%• NYHA I-II 10%

IV 50%

AF in diastolic dysfunction

• Prevalence ~ 10%• Risk related to degree of

diastolic dysfunction (echo) -

hazard ratio 3.3 5.3

AF IN HEART FAILURE

NEW YORK HEART ASSOCIATION FUNCTIONAL CLASS

Pre

vale

nce

of

AF

(%

)

60

40

20

0

I II-III III-IV IV

Maisel, Stevenson AJC 2003;91:2-8

SOLVD prevention

SOLVD treatment

V-HeFT

CHF-STAT

DIAMOND CHP

GESICA

CONSENSUS

DOES AF INCREASE CHF MORTALITY?

Framingham Study: evaluated temporal effect ofdevelopment of AF or CHF on mortality

Mortality HR (95% Cl)Men Women

Patients with AF

Add CHF 2.7 (1.9 - 3.7)

3.1 (2.2 - 4.2)

Patients with CHF

Add AF 1.6 (1.2 - 2.1) 2.7 (2.0 - 3.6)

Wang et al. Circulation 2003;107(23)2920-2925

• Incidence:AA (n = 223) - 20%Caucasian - 38%

• AA: younger (67 vs 74, p .001)HT (87% vs 78%, p .01)Prior CHF (79% vs 71%, p .01)Less CAD Dx

• AA lower odds of AF (49%) after adjustment for EF, age, gender, meds, DM, CHF etiology

Ruo et al JACC 2004; 43:429 EPOCH study patients N = 1373; 37% with AF Kaiser database

AF AND RACE IN PATIENTS HOSPITALIZED WITH CHF Dx

AF IN WOMEN

• Although risk is higher in men, 53% of all AF pts are women

• Women with CHF have 14x risk of AF, 8.5x risk in men

• Suggestion that embolism in women > men

• More sx, higher VR

• Higher proarrhythmia risk with AARx

19.2 %

EFFECT ON MORTALITY OF AF IN HEMODIALYSIS PTS (INDEPENDENT OF EF)

Cu

mu

lati

ve s

urv

ival 1.2

.8

.4

00 10 20 30 40 50

MosVazquez et al AJC 10.1.03 N = 190

71.3 %SRN=164

AFN=26

c

INFLAMMATION AS A RISK FACTOR FOR AF

Aviles et al Circulation 2003;108:3006 N = 5806 Cardiovascular Health Study (5% AF at baseline)

AF

fre

e su

rviv

al (

%) 100

95

90

85

800

Pts w/CRP level < median (1.92 mg/liter)

Pts w/CRP level > median (1.92 mg/liter)

0 1 2 3 4 5 6 7Yrs

OBSTRUCTIVE SLEEP APNEA AND INCIDENT AF

JACC 2007;49:565

0 2 4 6 8 10 12 14

OSA

No OSA

15

10

5

0Cu

mu

lati

ve f

req

uen

cyo

f A

F (

%)

Years

POTENTIAL MECHANISMS OF ASSOCIATION OF AF AND OSA

• Diastolic dysfunction with increase in LA size• Negative intrathoracic pressure fluctuations

leading to transmural pressure changes and wall stress

• Ion channel changes– stretch-sensitive– catacholamine-sensitive (apnea-related

increase)– vagal tone increase (end-apneic periods)

• Systemic inflammation associated with OSA• Hypoxemia• Hypercarbia• sympathetic drive

AF DURING ACUTE MIIncidence: 11% on entry

11% during hospitalizationCorrelations: Age

Anterior MIKillip IVPrior MICHF*

Outcomes:Higher death rates (indep. predictor)

- In hospital* 25% (vs 16% no AF)- 30 days* 29% (vs 19%)- 1 yr 48% (vs 33%)

Reinfarction* Higher in AF developing during MI

Rathmore et al, Circulation 3.00, N = 106,780 medicare pts 65 yo ((79)>

AF AND SUDDEN CARDIAC DEATH MORTALITY

• In the AVID Registry, AF present in 23% of patientsAF independent risk factor of SCD mortality (RR=1.20; P=.02)

• In MUSTT and MADIT II, AF was the second largestindependent risk factor for SCD

• CASS Registry: AF independent risk factor for SCD

• V-HeFT I and V-HeFT II: no correlation betweenmortality and AF

The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators.N Engl J Med. 1997;337:1576 Wyse et al. J Interv CardElectrophysiol. 2001;5:267 Zareba. Presented at NASPE 23rd

Scientific Session; May 2002 Cameron el al. Am J Cardiol. 1988;61:714

MANAGEMENT OPTIONS IN AF

Ventricular rate controlCA++ -blockers-blockersDigoxinAVN ablation

Restoration of NSRElectrical conversion Antiarrhythmic drugs

Maintenance of NSRAntiarrhythmic drugsDual chamber pacingAtrial overdrive pacingDual site atrial pacingAtrial septal pacingAF ablation

REASONS TO PERFORM EARLY RESTORATION OF NSR IN PTS WITH AF

• The longer the AF duration, the higher energy levels (transthoracic and internal) required for cardioversion

• Repeated atrial burst pacing leads to longer episodes of AF, eventuating in chronic AF (goats)

• The longer the AF episodes, the greater the atrial EP and histologic pathology

ANTIARRHYTHMIC DRUGS TO MAINTAIN SINUS RHYTHM

% of pts in Agent sinus rhythm at 1yr

• None 25%• Class 1A, and Sotalol 50%• Class 1C (propafenone,

flecainide) 50 - 60%• Dofetilide ~ 60%• Amiodarone 70 - 80%

• Dronedarone about 60%

Failure to convert AF to NSR does not mean that drug will not maintain NSR once it is achieved

EVALUTION OF AARx THERAPYTO MAINTAIN SR

• Time to 1st AF recurrence (should not be sole criterion of drug failure)

• Frequency of AF recurrences

• Duration of AF recurrences

• Symptoms during AF recurrences

AF: POST CONVERSION SR vs AFAND SERUM ALDOSTERONE LEVELS

SerumAldo(pg/ml)

200

150

100

50

0

Wozakowska-Kaplon et al PACE 2010; 33:561

SR maintained

AFrecurrence

24 h before CV24 h after CV

EURIDIS/ADONIS• Patient enrollment: 1237 patients

• Inclusion criteria: Presence of paroxysmalor persistent AF or AFL, with ≥ 1 documentedepisode in the 3 months prior to enrollment,and in normal sinus rhythm for at least 1 hour

• Primary endpoint: Time from randomizationto first AF/AFL recurrence

• Study medication: Dronedarone 400 mg BIDor placebo for 12 months

• Results: Dronedarone prolonged time to first recurrence of AF/AFL

Combined RR reduction: 25%Absolute RR reduction: 11% at 12 months

N Engl J Med 2007;357:987-999

DRONEDARONE*EURIDIS AND ADONIS TRIALS

• incidence of 1st (symptomatic) AFrecurrence

• VR during AF recurrences• hospitalization or death rates

(also ATHENA trial)• No substantial effect on QT interval

(? Atrial selectivity)• Low Torsades de pointes risk• Avoid in HF patients (ANDROMEDA study)

* Multiple ion-channel blockade; half-life 1-2 days

0 60 120 180 270 360

No. at risk

Placebo 409 192 156 133 112 90Dronedarone 828 450 389 347 307 262

DRONEDARONE FOR SR MAINTENANCE IN AF AND FLUTTER

Days

Singh et al NEJM 2007; 357:987

Cu

mu

lati

ve

in

cid

en

ce

(%

)80

60

40

20

0

Placebo

Hazard ratio, 0.75

P < 0.01

Dronedarone

ATHENA: OVERVIEW - 1

• Objective

A multicenter, multinational, double-blind, randomized placebo-controlledstudy of dronedarone in 4628 patientswith a recent history of AF/AFL who werein sinus rhythm or who were to be converted to sinus rhythm to assess theefficacy of dronedarone 400 mg bid for the prevention of cardiovascularhospitalization or death from any cause

Hohnloser SH et al J Cardiovasc Electrophysiol. 2008;19:69-73Hohnloser SH et al N Engl J Med 2009;260:668-678


• Patients representative of general AFpopulation

– History of paroxysmal or persistent AF/AFL– Aged ≥ 75 years with or without additional

risk factors

– Aged ≥ 69 years and ≥ 1 risk factor (HT, DM prior CVA/TIA, LA diameter ≥ 50 mm, LVEF < 40)

Hohnloser SH et al J Cardiovasc Electrophysiol. 2008;19:69-73: N Engl J Med 2009;260:668-678


• Primary endpoint: Time to first CV hospitalization or death from any cause

• Secondary endpoints: All-cause mortalityCV hospitalization

Hohnloser SH et al J Cardiovasc Electrophysiol. 2008;19:69-73;N Engl J Med 2009;260:668-678

ATHENA: SUMMARY

• Dronedarone significantly prolongs timeto first CV hospitalization in patients withparoxysmal or persistent AF andassociated CV risk factors

• Reduction in CV hospitalization mainly dueto admissions for AF

• The 24% reduction in cardiovascular hospitalization or death from any cause wasgenerally consistent in all subgroups based on baseline chracteristics ormedications

0 6 12 18 24 30

No. at risk


ATHENA: DRONEDARONE AND CV EVENTS IN AF

Primary outcome (1st hospitalization due to CV events or death)

Mos

Hohnloser et al NEJM 2009; 300:668

Cu

mu

lati

ve

in

cid

en

ce

(%

)

50

25

0

Placebo

P < 0.001

Dronedarone

0 6 12 18 24 30

No. at risk


ATHENA: DRONEDARONE AND CV EVENTS IN AFDeath from CV causes

Mos

Hohnloser et al NEJM 2009; 300:668

Cu

mu

lati

ve

in

cid

en

ce

(%

)

5.0

2.5

0

P < 0.03Dronedarone

Placebo

ANDROMEDA: OVERVIEW -1

• Designed to evaluate dronedarone,400 mg BID, on all-cause death orhospitalization for worsening heart failure

• Enrolled 627 of 1000 patients (310 and 317in the dronedarone and placebo groups,respectively)

• Patients had relatively severe heart failureand had been hospitalized, or referred to aspeciality heart failure clinic for worseningsymptoms

Kφber L: et al N Engl J Med 2008;358:2678-2687

ANDROMEDA: OVERVIEW - 2

• 38% of subjects had a history of AF/AFLand 25% had AF/AFL at enrollment

• Primary composite endpoint : all-causemortality or hospitalization for heartfailure

• Trial terminated because of a two-foldincrease in mortality in dronedaronegroup

Kφber L: et al N Engl J Med 2008;358:2678-2687

ACC / AHA / ESC GUIDELINES:RISK-STRATIFIED ANTITHROMBOTIC Rx

Risk factors: HF, LV EF 0.35, Hx HT

Fuster et al Eur Heart J. 2001;22:1852-1923

Age < 60, no HDAge < 60 + HD, no risk factorsAge > 60Age 60, DM or CAD

Any age + risk factors or thyrotoxicosis

Rx

ASA (325 mg/d or no Rx)ASA (325 mg/d) Warfarin (INR 2.0 - 3.0)Warfarin (INR 2.0 - 3.0) low dose ASA (class IIb) Warfarin (INR 2.0 - 3.0)

ACC / AHA / ESC GUIDELINES:RISK-STRATIFIED ANTITHROMBOTIC Rx

Risk factors: HF, LV EF 0.35, Hx HT

Rx

Age 75 (pts c risk Warfarin (INR -2.0) bleed - esp )

Rheumatic HD, prosthetic Warfarin (INR 2.5-3.5 heart valves, prior or higher maythromboembolism, be appropriate)persistent atrialthrombus on TEE

Fuster et al Eur Heart J 2001;22:1852-1923

RISK STRATIFICATION FORANTICOAGULATION IN AF:

CHADS2 Score

Points

• Congestive heart failure 1• Hypertension 1• Age 75 years or older 1• Diabetes mellitus 1• Stroke or TIA history 2

Gage BF et al JAMA 285: 2864-2870; 2001

ANTICOAGULATION RECOMMENDATIONS BY CHADS2 SCORE

• CHADS2 0– Low risk (0.5%/yr)– ECASA 325 mg qd

• CHADS2 1-2– Intermediate risk (1.5-2.5%/yr)– Warfarin (INR 2.0-3.0) > ECASA 325 mg qd

• CHADS2 3– High risk (5.3-6.9%/yr)– Warfarin (INR 2.0-3.0) unless contraindicated

VITAMIN K ANTAGONISTS IN AF

• Reduce stroke by 38%, compared to aspirin

• Recommended in high risk patients with AF

• Only 40-50% of ideal patients receive VKA in Western countries

–Many patients considered unsuitable

–Due to poor INR control, concern about bleeding

–Patient preference

In patients with AF, unsuitable for VKA therapy, addition of clopidogrel to aspirin will reduce the risk of major vascular events, at acceptable risk of major bleeding

HYPOTHESIS OF ACTIVE A

• All patients received aspirin at a recommended daily dose of 75-100 mgs

• Patients were randomized, double blind, to clopidogrel, 75 mg per day, or matching placebo

ACTIVE A - STUDY TREATMENT

OUTCOMES AND STATISTICAL POWER

• Primary outcome was a composite of major vascular events:

–Stroke, myocardial infarction, non-CNS systemic embolism or vascular death

• Secondary outcomes

–Stroke

–Major hemorrhage

• 7500 patients planned to achieve 88% power to detect 15% reduction in primary outcome (1600 events)

STUDY CONDUCT

• 33 Countries, 580 centers

• 7554 patients enrolled between

June 2003 and May 2006

• Final follow up in November 2008

–Median follow up 3.6 years

–Follow up was complete in

99.4% of patients

BENEFITS AND RISKS: COMPARED TO WARFARIN

Effects

WarfarinversusAspirin

Clopidogrel & AspirinversusAspirin

Meta-analysis*(RRR)

ACTIVE A(RRR)

Reduction in stroke - 38% -28%

Increase in intra-cranial bleed +128% +87%

Increase in extra-cranial bleed +70% +51%

*Hart RC et al. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have non-valvular AF . Ann Intern Med 2007: 146: 857-67

RE-LY: A Non-inferiority Trial

Atrial fibrillation ≥1 Risk Factor

Absence of contra-indications951 centers in 44 countries

R

Warfarinadjusted

(INR 2.0-3.0)N=6000

Dabigatran Etexilate

110 mg BIDN=6000

Dabigatran Etexilate

150 mg BIDN=6000

Blinded Event Adjudication.

Open Blinded

Ischemic/Unspecified Stroke

D 110 mg vs. Warfarin


RR =1.1195% CI = 0.89-1.40P = 0.35

RR = 0.7695% CI = 0.60-0.98P = 0.03

Years of Follow-up

Cu

mu

lati

ve H

azar

d R

ates

0.0

0.02

0.04

0.06

0.08

0 0.5 1.0 1.5 2.0 2.5

Dabigatran110

Dabigatran150

Warfarin

Hemorrhagic Stroke



RR = 0.31

95% CI =0.17-0.56

P <0.001

RR =0.26

95% CI =0.14-0.49

P <0.001

Years of Follow-up

Cu

mu

lati

ve H

azar

d R

ates

0.0

0.01

0.02

0.03

0.04

0 0.5 1.0 1.5 2.0 2.5

Dabigatran110

Dabigatran150

Warfarin

Rhythm Control • Loss of AV synchrony may produce sx • Prevents remodeling effects of AF • May play a role in stroke prevention

Rate Control • Anti-arrhythmic therapy is only

~ 60% effective long-term • Pro-arrhythmia and other side-effects • Many symptoms are relieved with

adequate control of rate

RATIONALE:RATE CONTROL vs RHYTHM CONTROL

ADVANTAGES OF RATE CONTROLVS RHYTHM CONTROL - 1

• Rate control (with anticoagulation):- No or few Sx of AF- Greater degree of structural heart

disease (e.g., requiring amiodarone)- Adverse response to AA Rx- Greater risk of proarrhythmia

EFGenderQT

ADVANTAGES OF RATE CONTROLVS RHYTHM CONTROL - 2

• Rhythm control:- Sx with AF that impact QOL- Sx despite adequate rate control- Young age- No or little structural heart disease- No or immediate need for AA Rx with

significant side effect profile- Contraindication to anticoagulation- 1st AF episode

AF FOLLOWUP INVESTIGATION OF RHYTHM MANAGEMENT (AFFIRM) TRIAL

Inclusion criteria:• 65 y.o. or other risk factor for stroke or

death*; 6 hrs AF in past 6 mos• FU 3.5 y• Rate control group 80/min rest, 110/min

with 6 min walk• End points

1º - overall mortality2º - composite: death, stroke, bleed,

cardiac arrest

* HT 70%, CAD 38%, LAE 65%, prior TIA, CHF 24%, avg EF 55%

NEJM 12.5.02 N = 4060 enrolled, 7401 screened

>

<

>

AF FOLLOWUP INVESTIGATION OF RHYTHM MANAGEMENT (AFFIRM) TRIAL

Cu

mu

lati

ve

mo

rtal

ity

(%)

20

10

0Deaths: 0 1 2 3 4 5No. (%) YearsRhythm control 0 80 (4) 175 (9) 257 (13) 314 (18) 352 (24)Rate control 0 78 (4) 148 (7) 210 (11) 275 (16) 306 (21)

NEJM 12.5.02

Rate control

Rhythm control

p = 0.08

AFFIRM: ADVERSE EVENTSRate Rhythm

control control

Ischemic stroke 79 (5.7%) 84 (7.3%)

INR 2.0 24 (30%) 18 (22%)

INR < 2.0 28 (35%) 17 (20%)

Not taking 26 (33%) 48 (58%)warfarin

AF at time 45 (69%) 25 (36%)of event

>

AFFIRM: LIMITATIONS

• Enrolled older, high risk pts• Chronic or paroxysmal AF could be enrolled;

PAF pts in rate control arm may have had NSR at times (52% of pts in rate control arm were in NSR at randomization); some pts in rhythm control arm likely had AF at times

• AF recurrences and durations not known over time in rhythm control group; periods of NSR not known in rate control group

AFFIRM IMPLICATIONS I

• Studied patients presumably required long-term Rx and had risk factors for stroke

• Coumadin should be continued in patients who are thought to be rhythm controlled

• AA drugs are not an alternative to coumadin

AFFIRM IMPLICATIONS II• Rate control carries no higher mortality or

lower functional benefit over rhythm control

• Did not answer the question of whether SR is better than AF with rate control

• Compared current pharmacologic strategies– Imperfect rhythm control– Incomplete monitoring of rhythm (single

ECG at FU; no Holter data)• Decision to rate or rhythm control should be

based on symptoms

POTENTIAL NEW MANAGEMENT STRATEGIES IN AF

AND PTS AT RISK FOR AF

ACE inhibitorsARBsAntiinflammatory agents

ASAStatinsFish oil

EFFECT OF ENALAPRIL ON AF INCIDENCE* IN PTS WITH LV DYSFUNCTION (SOLVD STUDY)

Fre

edo

m f

rom

AF

1.0

.75

.50

0

* Most episodes were paroxysmal

Vermes et al Circulation 2003;107:2926-2931AF developed in 55 / 374

Enalapril n = 186 (5%)

Placebo n = 188 (24%)

Risk reduction 19%

0 1 2 3 4 5Time (yrs)

POSSIBLE EFFECT ON ATRIAL REMODELING IN AF BY AT RECEPTOR BLOCKERS*

Pts free of AFrecurrences (%)

.0

.9

.8

.7

.6

.50 60 120 180 240 300 360

Amio + Irbesartan 150-300 mg/d

Amio 400 mg

FU (days):

Madrid et al Circulation 2002;106:331 N = 154

* Effects: Reduction of fibrosis Prevention/reduction of apoptosis

Less shortening of atrial refractory period during rapid atrial rates

HT AND NEW-ONSET AF (LIFE STUDY)P

rop

ort

ion

of

pts

w

ith

fir

st e

ven

t (%

) 8

6

4

2

00 12 24 36 48 60

Months

Wachtell et al JACC 2005; 45:712 N = 9193, 150 Losartan, 221 Atenolol

HR: 0.67, p<0.001

LosartanAtenolol

HT AND AF (LIFE STUDY):SUMMARY OF RESULTS

• Results of AF outcomes are independent of BP reduction

• AF increases cardiac morbidity/mortality in HT with LVH

• Losartan reduces AF recurrence risk in pts with AF history

• Losartan reduces incidence of new-onset AF (33%)

• Potential mechanisms- LV and LA hypertrophy regression - Atrial remodeling reversal- Reduction in atrial fibrosis

0 2 4 6 8 10 12

No. at risk

Placebo 720 520 454 407 377 344 254Valsartan 722 524 465 423 383 356 260

VALSARTAN AND 1st AF RECURRENCE

Mos since randomization

Gissi - AF NEJM 2009; 360:16

Pro

ba

bili

ty o

f 1

st

AF

re

cu

rre

nc

e

N = 1,442 CVD, DM or LAE;LVEF > 40% in > 90%; Lone AF ~ 10%; 70% on AARxP = 0. 83

.6

.4

.2

0

PlaceboValsartan

STATIN USE AND IN-HOSPITALARRHYTHMIAS IN ACS

Vedre et al, GRACE registry 1999-2007AJC 2009;104:1613 N=64, 679, 27% statin use

Pat

ien

ts (

%)

10

8

6

4

2

0VT/VFCA AF/flutter Hospital

death

4.3

7.4 6.98.2

3.2

5.5

Prior statin No prior statin

NEW-ONSET AF AFTER HOSPITAL ADMISSION FOR CAD STRATIFIED BY STATIN USE WITHIN

ONE MONTH OF HOSPITAL DISCHARGE

Kulik et al AJC 2010; 105:1655 Medicare database 1995-2004 N = 29,088

Inci

den

ce o

fN

ew A

F (

%)

100

50

00 60 120

Months post-dischargeAt risk:Statin 8,450No statin 20,638

2,2476,711

146841

Adjusted HR 0.90 ± 0.03 P = 0.0006

No Statin Statin 5 y: 38.3% 32.6%10y: 58.0% 51.2%

Statin n/M Control n/M OR 95% Cl OR

MIRACL 93/1539 96/1548 0.97Tveit 18/51 17/51 1.09Dernellis 14/40 36/40 0.06ARMYDA3 35/101 56/99 0.41Chelio 2/20 5/20 0.33Ozaydin 3/24 11/24 0.17

P = .02 0.39

META-ANALYSIS OF RCTS: EFFECT OF STATINS ON AF

Fauchier et al JACC 2008; 51:828

.02 1 2 5

Rx Control Favors

All AF


Primary prevention (post-operative or new onset AF)

Statin n/M Control n/M OR 95% Cl OR

MIRACL 1 25/1421 23/1440 1.10ARMYDA 3 35/101 56/99 0.41Chelio 2/20 5/20 0.33

P = NS 0.60


.02 1 2 5

Rx Control Favors


AF Recurrence (FU ≥ 6 wks)


.02 1 2 5

Rx Control Favors

Statin n/N Control n/N OR 95% Cl OR

MIRACL 2 68/118 73/108 0.65Tveit 18/51 17/51 1.09Dernellis 14/40 36/40 0.06Ozaydin 3/24 11/24 0.17

P = .06 0.33

POTENTIAL CANDIDATES FOR CURATIVE AF ABLATION:

PATIENT CHARACTERISTICS

• Frequent paroxysmal AF (not persistent)

• Frequent isolated PACs on monitoring• Lone AF• Younger patient and minimal HD• Focal AF

REVIEW OF ABLATION STUDIES

• Most patients:

Young (55 y.o.)Preserved LVEF (~ 60%)LA diameter ~ 5 cm

• 1º end point usually AF recurrence(assessed by various means)

• No RCTs on stroke risk, death

• Short FU

Teresawa et al Annals Int Med 2009;151:191

PREDICTORS OF LACK OF SUCCESS OF AF ABLATION

• Persistent AF

• LA volume (>130 cc) (echo and CT)

• LA diameter >5cm (TEE)

• Low or absent voltage of atrialelectrograms (indicating scar)

LESS CONSISTENT PREDICTORSOF FAILED AF ABLATION

• LA diameter (TTE)• Hypertension• Age, gender• AF duration• Structural heart disease including

valvular disease• LVEF• DM• CAD

LEFT ATRIAL APPENDAGE OCCLUSION

• Device (WATCHMAN) must be left in theleft atrium

• Alternative: Minimally invasive epicardialablation

• NOT ALL AF ARISES FROM THE LEFT ATRIAL APPENDAGE! Up to 10% of emboli

will not be approached by this method

• May have best use in patients who arerefractory to warfarin

atrial fibrillation nora goldschlager, m.d. macp, facc, faha, fhrs cardiology – san francisco...

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