Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC

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1 Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG confirms atrial fibrillation (AF) with rapid ventricular response rate. Physical exam reveals: BP: 160/95 mmhg Pulse: 148 bpm Chest clear Relevant past history: Small heart attack 5 years earlier No further symptoms of angina Copyright Not for Sale or Commercial Distribution Unauthorised use prohibited. Authorised users can download, display, view and print a single copy for personal use Ethel s ECG reveals AF, ventricular rate 160 bpm. Probable old inferior infarction and probable left ventricular hypertrophy (LVH) Current medications include: Losartan 50 mg q.d. Acetylsalicylic acid (ASA) 81 mg q.d. Hydrochlorthiazide 25 mg q.d. Subsequent investigations revealed that Ethel s thyroid-stimulating hormone was normal and ECHO showed mild concentric LVH. Old inferior wall scar was found, left atrium 5.1 cm diameter. Discharged on same medications with addition of bisoprolol 5 mg q.d. Follow up ambulatory ECG: resting rate 50-55, frequent episodes of non-sustained AF. Ethel was started on oral anticoagulation and propafenone 150 mg t.i.d. She was initially well controlled, but reverted to AF in 4 months. Heart rate controlled at bpm with no symptoms. Options at this stage: a. Attempt cardioversion, adding amiodarone to maintain sinus rhythm b. Increase dose of propafanone and cardioversion c. Persist with rate control and oral anticoagulation Ethel was given metoprolol 5 mg IV x 2. Her heart rate slowed and then converted to sinus at 68 bpm. No evidence of acute ischemia was found on ECG. For the correct option for Ethel, see page 21. Dr. Warnica is a Professor, University of Calgary and Director, Cardiac Intensive Care Unit, Foothills Medical Centre, Calgary, Alberta. Perspectives in Cardiology / January

2 CardioCase discussion By far the most recent and extensive recommendations for the management of atrial fibrillation (AF) may be found in the following article: Canadian Cardiovascular Society Consensus Conference: Atrial Fibrillation AF affects approximately 200,000 to 250,000 Canadians and is associated with many common clinical conditions, such as: aging, thromboembolism, hypertension, valvular heart disease and heart failure. AF is responsible for substantial morbidity and increased mortality. Consequently, it places a tremendous burden on our healthcare resources. The predominant pattern of AF should be determined as defined by the American College of Cardiology/American Heart Association/ European Society of Cardiology guidelines for management of AF: First-detected AF Paroxysmal: AF is self-terminating within seven days of recognized onset Persistent: AF is not self-terminating within seven days or is terminated electrically or pharmacologically Permanent: AF in which cardioversion has failed or in which clinical judgment has led to a decision not to pursue cardioversion. When contemplating therapy for AF, decide on a strategy of cardioversion and attempted rhythm or rate control. Antiarrhythmic drug therapy to maintain sinus rhythm has not been demonstrated in randomized, clinical trials to improve prognosis or prevent thromboembolic complications in patients with AF. Therefore, drug therapy to restore and maintain sinus rhythm should be limited to those patients who have a greater symptomatic burden of AF. Rate control vs. rhythm control: decision making The following recommendations apply to recurrent AF outside the setting of reversible causes. Anticoagulation should be used according to subsequent sections of these guidelines, regardless of whether a rate or rhythm control approach is used. The recommendations are based on a primarily pharmacologic approach: 1. There is no evidence that either rhythm or rate control is superior to the other and both are recommended as acceptable initial Table 1 Determining rate vs. rhythm control Favours rate control Persistent atrial fibrillation (AF) Recurrent AF Less symptomatic > 65-years-of-age No history of congestive heart failure Previous antiarrhythmic drug failure Patient preference Favours rhythm control Paroxysmal AF First episode of AF More symptomatic < 65-years-of-age No hypertension History of congestive heart failure No previous antiarrhythmic drug failure Patient preference 20 Perspectives in Cardiology / January 2008

3 More on Ethel... Final comment The final choice with Ethel would be to persist with rate control and oral anticoagulation (answer c). She was asymptomatic. The large left atrium suggested difficulty in maintaining sinus rhythm and most importantly, the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study has shown that rate control is just as good as rhythm control, if not better, in the asymptomatic elderly. Adding higher doses or more potent medication in this population increases the risk of morbidity and mortality. approaches, except for permanent AF where rate control is recommended 2. The choice of rate control or rhythm control for initial therapy should be individualized and is determined by a number of factors, such as classification of AF, degree of symptoms, etc. (Table 1) Drug therapy may be used for conversion in patients with hemodynamically stable AF. Therapy to control the ventricular rate response to AF should be initiated before or simultaneously with therapy to convert the arrhythmia. Before attempting drug conversion, patients should be adequately anticoagulated to prevent post conversion thromboembolic complications. IV procainamide or ibutilide and oral propafanone or flecainide are the most effective agents for pharmacological cardioversion. Sotalol is ineffective in facilitating conversion to sinus rhythm. In the absence of a reversible cause, AF is usually recurrent. The one-year recurrence rate of AF in the absence of an antiarrhythmic drug is approximately 75%. Conversion of AF When attempting conversion of AF, it is important to remember the following: 1. Electrical or pharmacologic conversion should be considered in patients with AF who are hemodynamically stable 2. Immediate conversion to sinus rhythm is recommended in patients with AF who are hemodynamically unstable. Electrical cardioversion is more effective and is preferred over pharmacologic conversion in these patients 3. Rate control with anticoagulation therapy alone is acceptable while awaiting spontaneous conversion in patients with AF of < 48 hours duration 4. Pharmacological agents may be used to accelerate conversion of AF in patients with AF of < 48 hours duration. See below for specific drug recommendations 5. Antiarrhythmic drugs may be used to pre-treat patients before electrical cardioversion (to decrease early recurrence of AF and to enhance cardioversion efficacy) Perspectives in Cardiology / January

4 Table 2 Risk factor stratification High-Risk Factors History of stroke/tia Reduced LV function > 75-years-of-age Mitral stenosis Prosthetic heart valve Moderate-Risk Factors 65- to 75-years-of-age Diabetes Coronary artery disease without left ventricular dysfunction TIA: Transient ischemic attack LV: Left ventricular Recommended drugs for conversion of AF The recommended drugs for conversion of AF include: Ibutilide Flecainide Procainamide Propafanone Chronic oral amiodarone (less popular) Antiarrhythmic drugs When selcing antiarrhythmic drugs for the maintenance of sinus rhythm, it is important to place patients in the appropriate category. These include: 1. Patients with structurally normal hearts First choices: - Propafanone - Flecainide - Sotalol* Second choice is amiodarone Alternative choices include: - Disopyramide - Dofetilide** 2. Patients with structurally abnormal hearts CAD with normal ventricular function - First choice is sotalol* - Second choice is amiodarone - Additional choices include: a. Dofetilide** b. Propafanone Left ventricular (LV) dysfunction (with or without CHF) - First choice is amiodarone - Second choice is dofetilide** with LVH - First choices are: a. Sotalol b. Amiodarone c. Propafanone d. Flecainide Anticoagulation recommendations The following are the current recommendaitons for anticoagulation: 1. All patients with AF or atrial flutter should be stratified for risk of stroke and vascular events and for risk of bleeding with anticoagulation therapy 2. Patients with AF or atrial flutter at high risk of stroke should receive oral anticoagulation unless there is an excessive risk of hemorrhage 3. Patients with AF or atrial flutter at intermediate risk should receive either oral anticoagulation or acetylsalicylic acid (ASA) (75 to 325 mg q.d.) and low-risk patients may receive ASA, unless there is excessive risk of bleeding 4. Patients undergoing direct current cardioversion for AF or atrial flutter should receive therapeutic oral anticoagulation for three to four weeks prior to, and after, the procedure. Low risk patients may be cardioverted without oral anticoagulation if done within 48 hours of arrhythmia onset. 22 Perspectives in Cardiology / January 2008

5 Table 3 Antithrombotic therapy by risk factors Risk factors Recommended therapy Any high-risk factor or > 1 moderate-risk factor Warfarin (target INR 2.5, range 2.0 to 3.0) 1 moderate-risk factor ASA 75 mg to 325 mg q.d. or warfarin (target INR 2.5,range 2.0 to 3.0) No high-risk factors and no moderate-risk factors ASA 75 mg to 325 mg q.d. Transesophageal ECHO guided cardioversion (Assessment of Cardioversion Using Trans-esophageal Echocardiography [ACUTE] Trial Protocol) is an acceptable alternative to oral anticoagulation 5. When reversal of oral anticoagulation is required (such as for surgery), therapy should be discontinued five to six days beforehand. Consideration should be given to use of heparin or low molecular weight heparin during this period in higher-risk patients The overall risk of stroke in patients with AF is 4.5% per year. However, this risk varies according to the clinical factors associated with AF. In healthy, young AF patients with no other clinical conditions, the risk of stroke and other vascular events is < 1% per year. On the other hand, in elderly patients with multiple risk factors the risk of vascular events exceeds 10% per year; therefore, risk stratification should guide therapy. The 1998 American College of Chest Physicians risk stratification is widely accepted, comprehensive and recommended. Tables 2 and 3 outline the factors used to stratify risk and the antithrombotic therapy recommended for each risk group. Intermittent AF should be considered as an equivalent risk to permanent AF. Atrial flutter should also be managed with the same criteria as AF. In all patients, the risk of thromboembolism should be balanced against the risk of hemorrhage. High-risk patients should be anticoagulated to maintain an INR from 2.0 to 3.0. Intermediate risk patients may be treated with either ASA (75 mg to 325 mg q.d.) or anticoagulation. Low-risk patients may be treated with ASA if there is little risk of bleeding. In patients with AF of > 48 hours duration, adequate anticoagulation should be given for three to four weeks before and after cardioversion. If cardioversion is required more urgently, transesophageal ECHO, to rule out left atrial thrombus, should be performed prior to cardioversion and anticoagulation should be given for three to four weeks following the procedure. PCard * Contraindicated in females > 65-years-of-age taking diuretics ** Dofetilide is available in Canada through Health Canada s special access program Reference Canadian Cardiovascular Society Consensus Conference: Atrial Fibrillation. Can J Cardiol. 2005; 21(Suppl B):9B-73B. Perspectives in Cardiology / January

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