updates in the management of atrial fibrillation atrial fibrillation.pdf · director, clinical...

Paul C. Zei, MD PhD, FHRS, FACCDirector, Clinical Atrial Fibrillation Program

Brigham and Women’s Hospital

Associate Professor of Medicine

Harvard Medical School

Updates in the Management of Atrial Fibrillation

• Biosense Webster, Inc.• Research support• Scientific Advisory Board• Consulting

• St Jude Medical/Abbott• Consulting• Research support

• Varian/Cyberheart• Research support• Scientific Advisory Board

• Affera• Consulting

• Boehringer Ingelheim• Expert witness

Disclosures

• Understand the current indications, options, risks, and benefits of stroke prevention for atrial fibrillation

• Understand the current indications for medical therapy vs. catheter ablation for the control of rhythm in atrial fibrillation

• Understand the impact of risk factors and risk factor modification on atrial fibrillation clinical outcomes

Learning Objectives

• A 58 year old woman presents to your office with palpitations

• Started 2 months ago• Feels episodes lasting 15-20 minutes at a time• Has had 1-2 episodes per week since initial symptoms• Rapid, irregular heartbeat associated with dyspnea,

transient light-headedness• No obvious triggers/associations• Her watch tells her she has atrial fibrillation…

Case 1

• PMH: hypertension, ”metabolic syndrome” • Meds: losartan, HCTZ, metformin, atorvastatin• Rare ETOH, no drugs; FH – both parents had AF in their 70s• Exam:

• BP 135/80 mmHg, Pulse 65bpm, regular• BMI 34• Cardiovascular exam unremarkable – no murmurs/gallops, no

evidence of volume overload• Apple Watch data poor quality – unable to determine rhythm

Case 1

• ECG:

Case 1

A. 24 hour Holter MonitorB. 1-2 week “patch monitor”C. 4 week event monitorD. Have patient come back to the office when symptoms

recurE. Refer for an implanted monitor

Case 1: What is the best next diagnostic strategy?

Evaluation of a patient with new-onset palpitations

• Suspect atrial fibrillation, but the differential diagnosis is broad

• What are the options for ambulatory monitoring, and how do you choose the appropriate option?

• Patient symptom cadence must match monitor features best as possible– Symptom frequency

– Symptom duration

– What about asymptomatic patients?

Monitor OptionsHolter Monitor

“Patch” Monitor

LoopingMonitor

Event Recorder

Implanted Loop Monitor

Phone or watch based pulse device

Phoneinterface ECG recorder

Function Continuous monitoring; 3 leads & a box

Single lead continuousmonitoring

1-5 leads;continuous monitoring; sx or threshold events are saved

1 lead;patient activated recording

1 lead; implanted; looping and patient activated

Peripheral pulse via camera

1 lead ECG that interfaces with smart phone

Duration worn

24-72 hours

1-2 weeks Up to 4 weeks

Up to 4 weeks

2-3 years

Pros Cheap, familiar

Patient convenience, continuous recording

Longer recording duration

Patient comfort

High sensitivity; 100% patient compliance; long duration

Patient owns the data; watch/phone is always with them

Higher fidelitythan pulse data

Cons Short recording duration

1 lead only; reimburse-ment issues

Patient discomfort; lower compliance

Patient compliance; events missed

Invasive (minimal); requires explantation

Accuracy may be low?use in medical records

Patient compliance; ECG quality varies?use in medical records

Monitor OptionsHolter Monitor

“Patch” Monitor

LoopingMonitor

Event Recorder

Implanted Loop Monitor

Phone or watch based pulse device

Phoneinterface ECG recorder

Best Use Sx/event occur >daily;

Sx/eventsoccur >every few days

Sx/events occur >monthly

Symptomatic pts only

Rare events; failure of other modalities

Unclear –perhaps patient preference

Unclear –perhaps long-term tracking of symptoms

Exampleindications

PVC burden monitoring;Frequentpalps

New onset palps; PAF dx or monitoring

Syncope;Rare palps

Rare palp symptoms; skin reaction to ECG leads

Very rare events(syncope, etc.); cryptogenic stroke

tracking rate control

Trackingeffect of rhythm/rate control



Case 1: Question 1 -what is the best diagnostic strategy?



Case 1: What is the best next diagnostic strategy?

Perez et al, NEJM Nov 2019

New for 2020

• In a general population (420k) with an Apple Watch:– Irregular heartbeat detection rate is very low (0.52%)

– Detection rate is highest in those >= 65 years old

– Subsequent patch monitoring detected AF in ~35%

• Utility as a screening tool undetermined

• What is the appropriate sub-group to focus on?

• Is there any impact on clinical outcomes?

Evaluation of a patient with new-onset palpitations: Our patient

• Patient prescribed 2 week patch monitor

• Results show episodes of AF with RVR (up to 150 bpm)

• Episodes correlated with patient’s symptoms

Case 1: continued

• Stress test: 8 METS on Bruce protocol, no evidence of ischemia

• TTE: LVEF 65%, no WMA, no significant valvular disease; LA chamber size mildly enlarged

• TSH normal

• Referred for sleep study

• Started apixaban, metoprolol

Case 1: continued

• Summary so far:

– 58yo woman with HTN, DM, structurally normal heart with new diagnosis of paroxysmal AF

– Highly symptomatic episodes

– Why was apixaban chosen?

Next steps? AHA/ACC Guidelines

• A comprehensive treatment plan must address the three cornerstones of AF management:

1) prevention of thromboembolism

2) rate control

3) rhythm control

• Hospitalization should be considered in patients who are significantly symptomatic, hemodynamically unstable, or being started on an antiarrhythmic drug

• Electrical cardioversion can be performed as an outpatient procedure

• When the cause of AF is reversible, such as AF after cardiac surgery, no long-term therapy may be necessary

• Patients being treated by a cardiologist who continue to be symptomatic or are difficult to manage should be referred to an electrophysiologist

January CT, et al. AHA/ACC/HRS 2014 guideline for the

management of patients with atrial fibrillation. Circulation, 2014.

Stroke Prevention: 91% of stroke in AF is caused by blood clots that form in the left atrial appendage (LAA)1

1 Blackshear JL. Odell JA., Annals of Thoracic Surgery. 1996;61:755-759

Loss of mechanical atrial contraction of the LAA leads to

blood flow stasis

The stagnant blood may coagulate and form thrombus

Dislodgement of the thrombus, with distal embolization in the

cerebral circulation

Occlusion of the cerebral circulation leads to stroke

Images on file at Boston Scientific Corporation

Thrombus in the LAA

AF and stroke

• Risk without anticoagulation 0-12% annually

• Chronic and paroxysmal AFib appear to carry same risk of stroke

• Strokes from AF are more severe• Greater long-term disability and mortality

Stroke Risk and AF: CHA2DS2-VASc

(Camm AJ, ESC Guidelines, Eur Heart J

2010)

Complicated; greater advocacy in Europe Limited external validation Limited reclassification improvement

Bleeding risk on Anticoagulation

Patient factors affecting bleeding risk• Age• Prior major bleeding• Anemia• Kidney disease• Antiplatelet agents, NSAIDS• Hypertension (SBP > 160)• Prior stroke• High alcohol use• Moderate to severe liver disease• Low TTR / unstable INRs

These factors also affect risk of

stroke

Gage BF, et al. Am Heart J. 2006Fang MC, et al. J Am Coll Cardiol. 2011

Pisters R, et al. Chest. 2010Piccini JP, et al. Circulation. 2013

What statement about stroke prevention in AF is correct?

A. Per current guidelines, when anticoagulation for stroke prevention is indicated, warfarin or a DOAC are indicated. Any of these options are equally reasonable.

B. DOAC agents are preferred to warfarin in all patients with AF

C. In patients with severe mitral stenosis, warfarin is preferred over DOAC agents

D. All patients who have undergone successful catheter ablation for AF, with sinus rhythm on follow-up office ECG, may discontinue anticoagulation

Risk Factor Recommended Therapy

ESC AHA/ACC/HRS

CHA2DS2-VASc = 0None (including women age < 65

with no other risk factors)

“Reasonable to omit

antithrombotic therapy”

CHA2DS2-VASc = 1 NOAC > VKA Nothing, ASA, or OAC

CHA2DS2-VASc ≥2 NOAC > VKA NOAC or VKA

Mechanical valve (modern)VKA: INR 2.0-3.0 (AVR)

VKA: INR 2.5-3.5 (MVR)

NOAC = Novel oral anticoagulant; VKA = Vitamin K antagonistCove CL, Hylek EM. J Am Heart Assoc. 2013

ESC Guidelines: Camm AJ et al. Eur Heart J. 2012 AHA/ACC/HRS Guidelines: January CT et al. Circulation, 2014

When to anticoagulate: current guidelinesBoth guidelines recommend use of CHA2DS2-VASc

Risks Benefits

Options for stroke prevention

• Anticoagulation • Warfarin

• Dabigatran (Pradaxa)• Rivaroxaban (Xarelto)• Apixaban (Eliquis)• Edoxaban (Syvvasa)

• Atrial appendage ligation/occlusion?• Open chest• Endovascular / transcatheter (Watchman)

• Restore sinus rhythm?

• Longest track record

• Requires monitoring and redosing

• High risk of complications

• Time in INR range (TTR) determines benefit

• Mean TTR in US ~ 60%

Warfarin

DOACs/ NOACs: Bottom line results of clinical trials

• Dabigatran, a direct thrombin inhibitor, is superior to warfarin for stroke prophylaxis in AF, with less IC bleed

• Rivaroxaban, an oral factor Xa inhibitor, is noninferior to warfarin for the prevention of stroke or systemic embolism

• Apixaban, an oral factor Xa inhibitor, is superior to warfarin in preventing stroke or systemic embolism, and is associated with less bleeding and lower mortality

• Connolly, S., et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009 Sep 17; 361(12):1139-1151.

• Patel, MR, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011 Sep 8;365(10):883-91.• Granger, CB, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011 Sep 15;365(11):981-92.

LAA percutaneous occlusion

Implant Face Distal to

Ostium

Barbs Engage LAA

Wall

• Clinical trial demonstrated “non-inferiority” to warfarin

• High procedural complication rates early on, now better

• FDA approved in patients with AF and a contraindication or intolerance for anticoagulation (IIb level of evidence)

• Currently not indicated for stroke prevention if only due to patient preference

Stroke Prevention: 2018-2020 Updates in RED

• DOACS have greater pharmacological predictability, fewer drug-to-drug interactions and dietary restrictions, lower risk of intracranial bleeding than warfarin.

• Rapid onset/offset. Strict compliance is critical. If AC must be d/c’ed for a reason other than bleeding, consider another antithrombotic (FDA boxed warning).

• Renal function should be assessed prior to prescribing, as dosing for some agents must be adjusted for renal insufficiency. Renal function should be re-assessed when clinically indicated or at least annually.

• Decision on anticoagulation long-term should be based on stroke risk assessed via CHA2DS2-VASc, irrespective of AF burden or rhythm control strategy

• All agents now have a “reversal agent”: only given IV in hospital

– Dabigatran: Praxbind

– Rivaroxaban and Apixaban: Andexanet (AndexXa)

• Connolly, S., et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009 Sep 17; 361(12):1139-1151.

• Patel, MR, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011 Sep 8;365(10):883-91.• Granger, CB, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011 Sep 15;365(11):981-92.

Guideline recommendations for AF Stroke Prevention:Updates in Red (2019)

• DOAC/NOAC agents are recommended as first line therapy for patients meeting indication for anticoagulation and without contraindication to anticoagulation in general (or to DOAC agents in particular)

• Warfarin should only be used for patients– With mechanical heart valves– With moderate to severe mitral stenosis– Unable to tolerate DOAC– End-stage renal disease *

• LAAE devices can be considered in patients with contraindication/intolerance to oral anticoagulation (Class Iibindication)

• These recommendations carry Level IA-B level of evidence

January et al, 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation

Summary: stroke prevention

• AF is an independent risk factor for stroke.

• Anticoagulation should be considered for all patients with AF—regardless of whether a rhythm or rate control strategy is chosen, except with contraindications.

• AF pts with mitral stenosis or a mechanical valve should be treated with warfarinregardless of the presence or absence of other risk factors.

• CHA2DS2-VASc is recommended to risk-stratify patients with nonvalvular AF to determine the need for anticoagulation therapy.

• Long-term AC (factor Xa inhibitor, or direct thrombin inhibitor) is indicated for CHA2DS2-VASc ≥ 2 in most patients

• For low stroke risk (CHA2DS2-VASc =1), the MD/pt may consider no anticoagulation, anticoagulation, or use of aspirin depending on patient priorities (stroke prevention vs. fear of a major bleed).

• Mechanical left atrial appendage exclusion is a nascent technology; indications for use yet to be clarified. Currently reasonable if there are long-term contraindications to oral anticoagulation.

What statement about stroke prevention in AF is correct?

A. Per current guidelines, when anticoagulation for stroke prevention is indicated, warfarin or a DOAC are indicated. Any of these options are equally reasonable.

B. DOAC agents are preferred to warfarin in all patients with AF

C. In patients with severe mitral stenosis, warfarin is preferred over DOAC agents

D. All patients who have undergone successful catheter ablation for AF, with sinus rhythm on follow-up office ECG, may discontinue anticoagulation

Case 1 Follow Up

• Initiated metoprolol, apixaban, with control of episodes for 1 year thus far

• Referred to EP to establish care

• 66 year-old man presents to your office with 3 days of malaise and fatigue

• No other specific cardiac symptoms• He was pretty sure it started after his anniversary dinner

where he and his wife went through 2 bottles of wine• Avid road cyclist, about 150 miles per week. Last 2 rides

has noticed degraded performance; heart rate monitor showed elevated base HR, peak exercise HR (90bpm -> 180bpm)

Case 2

• PMH: known paroxysmal AF, diagnosed 2 years ago, HTN• TTE one year ago: normal EF, no structural heart disease, LA size

normal• Stress test one year ago: 15 METS, no evidence for ischemia

• Declined AC at that time• Meds: aspirin• Exam:

• No acute distress• BP 110/70, Pulse 110bpm, irregular• Normal cardiac exam otherwise

Case 2

• ECG

Case 2

Rhythm vs. Rate Control?

• The AFFIRM, RACE, and AF-CHF trials have shown no mortality benefit to a rhythm control strategy compared to a rate control strategy. – Rhythm control has never been shown to reduce stroke risk

• Therefore, a rate control strategy, without attempts at restoration or maintenance of sinus rhythm (SR), is reasonable in some patients with AF, especially those who are elderly and asymptomatic.– Rate control options: medication, “ablate and pace”

• If rate control offers inadequate symptomatic relief, restoration of SR may become a long-term goal and the patient should be referred to an electrophysiologist for rhythm control with drugs or ablation.

The Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and

rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347: 1825-1833.

• Cardioversion performed after TEE negative for thrombus• Patient agreed to anticoagulation with apixaban• What should the next steps be?

Case 2: continued

A. Initiate flecainide 100mg bid in addition to apixaban and metoprolol

B. Initiate flecainide 150mg-300mg prn AF recurrence in addition to metoprolol and apixaban

C. Refer for catheter ablationD. Refer for AV Junction ablation and pacemaker

Next Steps?

Rhythm Control Strategies

• Antiarrhythmic drugs• Daily dosing

• PRN dosing

• Catheter-based ablation

• Surgical ablation

A two-slide primer on antiarrhythmic drugs

Vaughan Williams Class I - Na channel blockade

• Flecainide PO: 50-150mg every 12 hrs

• Propafenone PO: 150-300mg every 8 hrs, or sustained release 225-425mg every 12

hrs

Vaughan Williams Class III – K channel blockade

• Amiodarone PO: 200mg TID x 2 weeks, 200mg BID x 2wks, then 200mg daily. Take

with meals.

• Monitor for hepatic, thyroid, pulmonary, ophthalmologic, skin toxicity

• Dofetilide PO: 125-500mcg every 12 hrs, based on renal function and QTc;

• must be initiated in the hospital

• Dronedarone PO: 400mg twice daily with meals

• Monitor for hepatotoxicity; contraindicated in permanent AF, low EF

• Sotalol PO: 80mg BID, to a maximum of 240-320mg/day, based on renal function

and QTc

• In-hospital initiation favored

• Less commonly prescribed: disopyramide, quinidine

AAD considerations – slide 2

• Class IC agents • Contraindicated in patients with “structural heart disease”

• May be used as maintenance or “pill in the pocket”

• Should be given with concomitant rate control agent to prevent rapidly conducting atrial flutter

• Class III agents• All agents can prolong QT interval (amiodarone less so)

• Dofetilide and sotalol should be initiated in the hospital

• Patients taking amiodarone should have periodic monitoring for organ toxicity

• Tried bid flecainide for 3 months and failed – not tolerated during exercise, not always effective

• Pt finally fed up with symptoms, failure of AAD• Referred to EP for ablation• What do you tell the patient to expect around the time of

ablation?• What do you do about AC and AAD after ablation?

Case 2: continued

• Arrhythmogenic triggers for AF in the pulmonary vein musculature demonstrated in 45 patients with PAF

Haissaguerre et al. NEJM 1998

Pulmonary Vein Triggers

Haissaguerre et al. NEJM 1998

• Ablation of these PV triggers resulted in reduction/elimination of AF

Why do we differentiate between paroxysmal vs. persistent AF when it comes to ablation?

Paroxysmal AF Persistent AF Long-standing persistent AF

Definition Episodes self terminate or via CV <7d

Episodes do not self terminate < 7d

Persistent AF >1 year

LA size Normal to mildly enlarged Mild to severely enlarged Severely enlarged

LA scar burden Low Moderate high

Efficacy of AAD Often effective Not as effective Usually refractory

When to offer ablation?

First-line therapy First-line OK, but after AAD failure best

After AAD failure

Ablation technique PV isolation alone PV isolation only probably still best

PV isolation; additional ablation likely needed

Catheter ablation efficacy

Excellent Not quite excellent, but still good

?, but likely low with current approaches

What happens during catheter ablation for AF?

• Typically performed under general anesthesia

• Vascular access (venous)

• Catheter advancement into the heart (RA)

• Transseptal puncture to access the left atrium (LA)

• Tools utilized – almost all cases performed using either radiofrequency energy (RF) or cryothermy (freezing), with a goal of creating permanent scar and resultant electrical conduction block

• Ablation delivered to circumferentially electrically isolate all pulmonary veins

• Additional ablation beyond PV isolation may be performed, particularly in patients with persistent or long-standing persistent AF

What happens during catheter ablation for AF?

Commonly used tools:

• Electroanatomic mapping

• RF energy: irrigated tip, contact force

• Cryoablation: balloon catheter

• ICE (intracardiac ultrasound)

What are the risks and benefits of AF ablation?

• For success … it depends

• Paroxysmal AF: Most studies in the past 10 years report between 60-80%, some as high as 90% success rates, defined as freedom from AF (with a variety of monitoring/reporting methods)

• Persistent AF: lower than PAF, probably 50-70% range

• Risks: between 1-12% reported depending on the experience of the center, operator– “Generic” risks – vascular complications, thromboembolic complications,

pericardial effusion and tamponade

– AF ablation specific risks• Pulmonary vein (PV) stenosis – nearly unheard of today due to more antral

ablation techniques

• Phrenic nerve injury – risk using cryo >>> RF, most recover within weeks to months

• Atrio-esophageal injury – unpredictable, but high mortality (nearly 100% without intervention, 50-60% with surgical repair; true event rate is unknown, but probably in the range of 1:500 to 1:1000

New for 2019/2020: CABANA

Catheter ABlation vs ANtiarrhythmic

Drug Therapy in Atrial Fibrillation

(CABANA) Trial

Douglas L. Packer MD, Kerry L. Lee PhD,

Daniel B. Mark MD, MPH, Richard A. Robb PhD

for the CABANA Investigators

Mayo Clinic Rochester

Duke Clinical Research Institute

National Heart, Lung, and Blood Institute

Compare Ablation to state-of-the-art drug therapy for

patients with new onset / undertreated AF

Primary Endpoint

• All-cause mortality, disabling stroke, serious

bleeding, or cardiac arrest

Major Secondary Endpoints

• All-cause mortality

• Death (all-cause) or cardiovascular

hospitalization

Purpose of CABANA

New for 2019/2020: CABANAPrimary Endpoint (Death, Disabling

Stroke, Serious Bleeding, or Cardiac Arrest) (ITT)

Primary Endpoint (Death, Disabling Stroke, Serious Bleeding, or Cardiac

Arrest (Per Protocol)

First Recurrence AF – Post Blanking* (ITT)

*Using CABANA Monitors

Adverse Events in CABANA Adverse Events in CABANA

• AF ablation shows trend towards improving combined endpoint (death, CVA, bleed, cardiac arrest)

• AF ablation far superior to drug therapy for maintenance of sinus rhythm

What to expect after AF ablation?

• Atrial tachyarrhythmias can occur in the first three months after ablation during the healing phase. These arrhythmias can be treated with medical therapy and often resolve. However, a repeat ablation procedure should be considered if atrial tachyarrhythmias persist.

• Patients should be anticoagulated for at least two months after ablation. Long-term oral anticoagulation should be considered in patients with a CHA2DS2-VASc score ≥2 regardless of the outcome after ablation.

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Calkins et al., Heart Rhythm Vol 14, No 10, October 2017

AHA/ACC Guideline recommendations for ablation: 2014 (updated 2017)

* Note: no mention is made of preferred energy source, ablation strategy, although evidence cited by guidelines favors RF

A. Initiate flecainide 100mg bid in addition to apixaban and metoprolol

B. Initiate flecainide 150mg-300mg prn AF recurrence in addition to metoprolol and apixaban

C. Refer for catheter ablationD. Refer for AV Junction ablation and pacemaker

Next Steps?

Medical vs. ablative rhythm control are reasonable; patient preference plays an important role

Patient elected to proceed with catheter ablation due to intolerance of medical therapy, active lifestyle

• 42 year-old man presents for general evaluation• Recent diagnosis of paroxysmal AF, about 1 year ago• Episodes well-controlled on metoprolol• PMH:

• HTN• Diabetes• Obstructive sleep apnea• Obesity (BMI 38)

• Exam: BP 135/90 mmHg, Pulse 55bpm, regular• ECG: sinus rhythm

Case 3

A. ObesityB. HtnC. OSAD. DiabetesE. A + BF. A + B + CG. All of the above

Currently available data supports intervention on these comorbidities in AF patients:

Proposed mechanism for AF promotion in at-risk populations

Treating the upstream inputs: Can we reduce AF incidence with reduction of these risk factors?

Sanders et al, Circ 2017

The known modifiable risk factors in AF:

• Hypertension

• Obesity

• Diabetes

• Sleep apnea

Data supporting risk factor modification

• LEGACY – weight loss leads to reduced AF burden w/o ablation

• ARREST-AF – improved control of multiple risk factors reduces AF burden after AF ablation (HTN, DM, weight)

• CARDIO-FIT – improved CV fitness leads to decreased AF burden after AF ablation

Sanders et al, Circ 2017

A. ObesityB. HtnC. OSAD. DiabetesE. A + BF. A + B + CG. All of the above

Currently available data supports intervention on these comorbidities in AF patients:

A. AF is a biologic disease, and there is no evidence that lifestyle modification impacts AF clinical outcomes

B. Reducing caffeine intake will reduce AF symptomsC. Reducing alcohol intake in moderate to heavy drinkers will reduce

AF burdenD. Increasing exercise level can increase AF burdenE. Increasing exercise level can decrease AF burden

Your patient asks about lifestyle changes that may impact their AF. You tell them (more than one may be correct):

Data supporting lifestyle modification

• Moderate to heavy alcohol drinkers with AF: abstinence significantly reduces AF recurrence

• On the other hand, no studies to date have demonstrated an association between caffeine intake and AF risk or burden

• We are often asked about stress level and AF burden/risk, but this has been very challenging to study

Voskoboinik et al, NEJM 2020

Exercise and AF burden

• Exercise quantity/burden demonstrates a ”U-shaped” relationship with AF incidence in males

• In females, data suggests decreasing incidence of AF with increasing AF burden

• In males, data suggest that there is such a thing as “too much exercise” as far as AF risk goes

Exercise Burden

AF Incidence

The New AF Treatment Paradigm: BWH Comprehensive AF Program

Electrophysiology Program• “Front Door” of the program• Clinical management• Ablation• LAA management• Device management• Anticoagulation

CV Medicine• Prevention• Hypertension• Other CV disease• HCM• Heart failure• Genetics

CT Surgery• Surgical ablation• LAA management

BWH CV Innovation Program

Endocrinology

Weight management

Sleep Medicine

Psychiatry

GI NutritionExercise

consultation

Remote monitoring center

Virtual consultation

Mobile Health

Exercise: high-performance

athlete

Geriatrics

Anticoagulation Management

Wellness

A. AF is a biologic disease, and there is no evidence that lifestyle modification impacts AF clinical outcomes

B. Reducing caffeine intake in heavy users will reduce AF symptomsC. Reducing alcohol intake in moderate to heavy drinkers will reduce

AF burdenD. Increasing exercise level can increase AF burdenE. Increasing exercise level can decrease AF burden

Your patient asks about lifestyle changes that may impact their AF. You tell them (more than one may be correct):

Summary: Key Take Home Points for Office Management of Atrial Fibrillation in 2020

Ambulatory monitoring

• We clinicians will be seeing more and more patients with personal ECG devices

• What to do about the data remains unclear – for now it is reasonable to take data into account in the course of standard medical diagnosis and management

Cornerstones of therapy for AF:

• Stroke prevention• CHA2DS2-Vasc should guide anticoagulation, but decision should be individualized

to the patient• DOAC agents are recommended over warfarin (except pts with mitral stenosis or

mechanical heart valves)

• Rhythm Control – catheter ablation is superior to medication for maintaining sinus rhythm

• Risk factor modification• Evaluation and treatment of known modifiable risk factors is indicated• Reduction of alcohol intake may improve AF outcomes• Exercise vs. AF burden has a complex relationship

• Appropriate use of ambulatory monitoring options in AF detection

• Appropriate strategies for stroke prevention in AF• Understanding the options available for rate and/or

rhythm control• Understanding the growing understanding of risk factor

and lifestyle inputs into AF clinical outcomes

Key Points

• Incorporate latest data and guideline recommendations for AF stroke prevention decisions

• If anticoagulation indicated, utilize appropriate guideline and data-based choices

• Consider referral to Electrophysiology for catheter ablation if rhythm control is desired

• Consider, evaluate, and intervene on modifiable risk factors for AF

Next Steps

Brigham and Women’s Hospital Cardiac Arrhythmia Service

FacultySunil Kapur, MDBruce Koplan, MD, MPHMelanie Maytin, MDDavid Martin, MDAmy Miller, MDWilliam Sauer, MDMichael Sweeney, MDUsha Tedrow, MD, MSPaul Zei, MD, PhD

FellowsMartin Aguilar, MDJohn Meriwether, MDPierre Qian, MDKenneth Quadros, MDAhmad Halawa, MDParinita Dherange, MD

Allied ProfessionalsTiffany Andrade, PA-CNicole Bourque, PA-CMegan Brady, PA-CLindsay Harris, NPPatrice Hoskins, PA-CJulie Shea, NPLaura Sifrig, PA-CLaurel Taylor, PA-C

Clinical and Research AdministrationShanise BelizaireAnne HarringtonChristine PellegriniDeb ManuelianArya Stark

EP Laboratory CV TechsJohn SpadaroJeff BellLisa BradyWilliam BurkeZachary ClarkeLori CoelhoRobert De La CruzDara GriffithFrank InglesePhilip JonesJulie MedinaDeb SinkNahomie VegaMelissa WegnerBrenda HuettmannMichael McCormick

EP Laboratory RNsBrian DunleaAdele NasrGregory KellyChris ShinnamonLaurie DemeulePeter DortBeverly CoronisEileen GwinnAnne Johnson

Cardiac Device TeamLindsay Harris, NPCarol Booth, RN

Heather O’NeilRoss WlodykaVictoria Perkins

Thank you!

[email protected]

@paulzei

+1 (650) 521-2173

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