Atrial Fibrillation: Drugs, Ablation, or Benign Neglect. Robert Kennedy, MD October 10, 2015

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1 Atrial Fibrillation: Drugs, Ablation, or Benign Neglect Robert Kennedy, MD October 10, 2015

2 Definitions 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014

3 Strategy Reversible triggers Anticoagulation Rate control Rhythm control

4 Reversible Triggers Thyroid disease screening Obesity Obstructive Sleep Apnea Hypertension Alcohol Exercise Smoking Valve disease

5 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014

6 Anticoagulation Risk stratification What is a significant event? Can you eliminate need for anticoagulation with rhythm control? Warfarin vs. novel agents vs. aspirin

7 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014

8 Rate vs. Rhythm Control: AFFIRM Trial Wyse et al. N Engl J Med 2002;347:

9 Figure 13. Pharmacological management of patients with newly discovered atrial fibrillation (AF). *See Figure 15. Fuster V et al. Circulation 2006;114:e257-e354 Copyright American Heart Association

10 Figure 14. Pharmacological management of patients with recurrent paroxysmal atrial fibrillation (AF). *See Figure 15. Fuster V et al. Circulation 2006;114:e257-e354 Copyright American Heart Association

11 Figure 16. Pharmacological management of patients with recurrent persistent or permanent atrial fibrillation (AF). Fuster V et al. Circulation 2006;114:e257-e354 Copyright American Heart Association

12 Rate Control Beta blockers Calcium channel blockers (nondihydropyridine) Digoxin Amiodarone Pace and ablate

13 Rhythm Control Dronaderone Propafenone Flecainide Sotalol Dofetilide Amiodarone

14 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014

15 Ablation is Salvation

16 Ablation Guidelines CLASS I 1. AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythmcontrol strategy is desired ( ). (Level of Evidence: A) 2. Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C) CLASS IIa AF catheter ablation is reasonable for some patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (157, ). (Level of Evidence: A) In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy ( ). (Level of Evidence: B) 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014

17 Ablation Guidelines CLASS IIb 1. AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or in- tolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired (154,167). (Level of Evidence: B) 2. AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III anti- arrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired. (Level of Evidence: C) CLASS III: HARM AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and after the procedure. (Level of Evidence: C) AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C) 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014

18 Benign Neglect Positives: Focus is quality of life Avoid side effects and complications Negative Still worry about stroke Rate control problems Association with other morbidities Heart failure with preserved EF Systolic heart failure development

19 Other Considerations Cardioversions Atrial Flutter Practical issues

20

21

22 Syncope Clinical diagnosis Sensitivity and Specificity of Tilt Table Testing with isuprel or nitroglycerin challenge just 80% Management Typically conservative for vasovagal or orthostasis Pacemaker ICD EPS

23 Arrhythmia vs. Neurocardiogenic/Vasovagal Age, sex, duration of recovery, presence of fatigue Sens 98%, Spec 100% VT vs. Bradycardia Duration of warning, recovery symptoms 63% sens, 88% spec Am J Med 1995

24 Syncope

25 Syncope

26 Syncope

27 Syncope Focus on clinical history to make diagnosis Limitation of tilt table testing Clinical history can strongly influence triage to outpatient vs. inpatient evaluation

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