ATRIAL FIBRILLATION. Michael Diamant and Luke Rannelli Internal Medicine PGY-3

Transcription

1 ATRIAL FIBRILLATION Michael Diamant and Luke Rannelli Internal Medicine PGY-3

2 OBJECTIVES Guidelines-based approach to the following: Initial diagnosis and work-up Management as an outpatient Rate control Rationale for rhythm control Anticoagulation (including NOACs) Management in an acute setting

3 MECHANISM

4 CASE 1 A 76F with a Hx of controlled HTN, hypothyroidism presents to your family practice office with fatigue x 7 days. Has occasional palpitations, feels an irregular pulse afeb HR 120s irreg BP 128/86 O2 98% RA Send for ECG, and she returns to your office

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6 CLUES FOR DIAGNOSIS Ventricular rate usually On ECG irregularly irregular ventricular response Predominant lack of P waves

7 CLASSIFYING AF Ventricular response Rapid: HR >110 Slow: HR <50 Pattern of occurrence First detection Paroxysmal - AF self-terminating within 7 days of onset Persistent - AF not self-terminating within 7 days, or terminated electrically/pharmacologically Permanent - when cardioversion has failed, or has been decided not to pursue it CCS Atrial Fibrillation 2010 Guidelines, ACC/AHA Atrial Fibrillation 2006 Guidelines

8 INITIAL WORKUP Rationale To identify risk factors for AF, which, if treated, could reduce or eliminate the occurrence of further AF To identify important risk factors, which, if treated, could improve the overall outcome of the patient, independent of AF To aid in assessing the prognosis of AF in the individual patient To assist in the selection of optimal AF therapy in the individual patient CCS Atrial Fibrillation 2010 Guidelines

9 RISK FACTORS Acute Infection Myo/pericarditis Coronary artery disease Hypothermia Stroke/SAH Surgery Drugs PE

10 RISK FACTORS Chronic Age (prevalence 4% age 60, 8% age 80) Hypertension Genetic/familial Endocrine (obesity, DM2, hyperthyroidism, pheo) Drugs (incl. EtOH) Valvular disease (mitral stenosis, possibly tricuspid stenosis) Congenital heart dz LV dysfunction pulmonary hypertension/osa lung cancer

11 INITIAL WORKUP Full history and physical FMHX and Med Hx, BP/HR, precordial exam, symptoms/signs of OSA ECG Consider Holter if not captured on 12-lead Also assess for evidence of electrical or structural heart disease CBC, coags, lytes, Cr, liver panel, TSH LDL, FBG (or HgbA1c) Echo Evaluate atrial and ventricular size, ventricular fxn, valvular or congenital heart dz, filling and PA pressures Derived from CCS Atrial Fibrillation 2010 Guidelines

12 MANAGEMENT Should I choose rate or rhythm control? Should I choose ASA, warfarin, or a NOAC? How do I balance this with bleeding risk?

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14 MANAGEMENT: RATE VS. AFFIRM TRIAL RHYTHM CONTROL Randomized (n=4060) to rate control (with warfarin to INR 2-3) vs. rhythm control (off anti-coagulation if in sinus rhythm >4 weeks) Found a trend toward higher rate of 5-year mortality in rhythm control group (HR 1.15 [95% CI ], p=0.08) lower rates of warfarin use in rhythm group, and only ~62.6% in sinus at 5 years Higher rates of adverse events in rhythm control Risk of death higher among rhythm control patients of older age, or those with CAD or HF Wyse et al., NEJM 2002

15 CCS Atrial Fibrillation Guidelines Focused Update

16 MANAGEMENT: RATE First line therapy CONTROL metoprolol (starting dose mg BID, max dose 100 mg BID) bisoprolol (starting dose mg daily, max dose 10 mg daily) diltiazem XR (starting dose 60 mg BID or mg daily, max dose 480 mg/day) verapamil (IR form starting dose 80 mg q8h, max dose 480 mg/day; XR form starting 180 mg qhs, max dose 540 mg ohs) Second line therapy Agent from other class, or digoxin (range daily)* *CCS Atrial Fibrillation Guidelines Focused Update

17 MANAGEMENT: RATE CONTROL Re-assessment in follow-up includes determine the following: Symptomatic? Side effects from drugs? Resting heart rate What am I targeting?

18 MANAGEMENT: RATE RACE2 TRIAL CONTROL Randomized (n=614) pts to strict (HR <80) vs. lenient (HR <110) Avg HR 75 vs. 85 (after f/u phase), and lenient had fewer drugs and MD visits Two groups non-inferior for composite outcome (incl. CV and all-cause mortality), NS difference in symptoms and adverse effects Therefore, CCS Guidelines suggest target HR <100 Van Gelder et al., NEJM 2010; CCS Atrial Fibrillation Guidelines Focused Update

19 MANAGEMENT: RHYTHM CONTROL Ideally adjusted to individual patient Know your side effects When in doubt or uncomfortable, refer to cardiologist or internist In Calgary, there is also an AF Clinic CCS Atrial Fibrillation Guidelines Focused Update

20 CCS Atrial Fibrillation Guidelines Focused Update

21 MANAGEMENT: RHYTHM CONTROL Two main approaches: Pill-in-pocket For low-burden occurrence (typically infrequent but symptomatic) Flecainide is common Rx (dose mg) caution with AF >Aflutter > VT/VF, to be taken with metoprolol

22 MANAGEMENT: RHYTHM Two main approaches (cont.): Long-term maintenance therapy For high-burden occurrence CONTROL Sotalol (Dosing range mg BID) Can prolong Q-T and cause Torsades, caution in elderly, females Reduce to once daily dosing with GFR 40-60, contraindicated if GFR <40 and LVEF <35% Amiodarone Most effective at ensuring normal sinus rhythm Complicated dosing, pharmacodynamics with multiple toxicities Need close monitoring for side effects (following slide)

23 PARAMETER MONITORED FREQUENCY OF OCCURRENCE, % WHAT TO ORDER OR PERFORM HOW OFTEN CNS (ataxia, dizziness) 4-9 Physical examination Every f/u visit Corneal deposits 4-9 Slit lamp examination Annually Optic neuropathy Unknown Ophthalmologic examination Baseline, q6-12 mo Pulmonary toxicity 2-17 Chest x-ray scan, pulmonary function tests (and DLCO) Baseline, q6-12 mo Thyroid complications 2-6 Free T4 level, TSH level Baseline, q6-12 mo Photosensitivity 3-10 History, physical examination Baseline, q6-12 mo Blue discoloration of skin (Smurf or Avatar syndrome) < 9 History, physical examination Baseline, q6-12 mo GI (nausea, vomiting, anorexia) 4-33 Weight, physical examination, and history Baseline, q6-12 mo Liver toxicity 4-9 AST, ALT, bilirubin Baseline, q6- Frankel et al., 12 Can mo Fam Physician 2013

24 MANAGEMENT Cardioversion For acute or recent onset, refractory, or unknown if symptoms are related to AF Limited success based on atrial size, other provoking factors Ablation Mounting evidence suggesting utility as first-line agent Procedure: Pulmonary Vein Isolation Successful ~60-70%, up to 90% with repeat procedures Discussion re: benefits vs. complications, logistics re: antithrombotics best left to Cardiologist MANTRA-PAF Trial, RAAFT-2 Trial; CCS Atrial Fibrillation Guidelines Focused Update

25 MANAGEMENT - ANTICOAGULATION

26 CCS Atrial Fibrillation Guidelines Focused Update

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28 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation MANAGEMENT ANTICOAGULATION OPTIONS

29 MANAGEMENT ANTICOAGULATION STUDIES Aspirin Warfarin G et al., Ann Intern Med 2007; CCS Atrial Fibrillation Guidelines Update on Prevention of Stroke and Systemic Thromboe

30 MANAGEMENT ANTICOAGULATION STUDIES Aspirin vs Warfarin Major hemorrhage ASA vs placebo equivalent Warfarin vs placebo 0.5% risk/year et al., Ann Intern Med 2007; CCS Atrial Fibrillation Guidelines Update on Prevention of Stroke and Systemic Thromboem

31 MANAGEMENT - ANTICOAGULATION Dabigatran 1 Rivaroxaban 2 Apixaban 3 Stroke /- - Bleeding / - - Dosing Dabigatran: 110 or 150 mg BID (or 75 mg BID if GFR 15-30) Rivaroxaban: 20 mg daily, or 15 mg daily if GFR Apixaban: 5 mg BID, or 2.5 mg BID if Age 80, weight <60 kg, or Cr >135 1 RELY Trial; 2 ROCKET-AF Trial; 3 ARISTOTLE Trial

32 MANAGEMENT - ANTICOAGULATION CCS Recommendation: We recommend that when OAC therapy is indicated for patients with nonvalvular AF, most patients should receive dabigatran, rivaroxaban, apixaban, or edoxaban (when approved) in preference to warfarin (Strong Recommendation, High-Quality Evidence). CCS Atrial Fibrillation Guidelines Focused Update

33 MANAGEMENT ANTICOAGULATION Exceptions Valvular Afib (MS, mechanical) NO DOAC Triple Anticoagulation Post ACS Plavix + warfarin, no ASA Anticoagulation Interruptions CCS Atrial Fibrillation Guidelines Focused Update

34 CASE 1 REVISITED A 76F with a Hx of controlled HTN, hypothyroidism presents to your family practice office with fatigue x 7 days. Has occasional palpitations, feels an irregular pulse Afib HR 120s irreg BP 128/86 O2 98% RA Send for ECG, and she returns to your office

35 CASE 1 REVISITED There is no other provoking factors based on history/physical, blood work, and echo She is started on bisoprolol, which is uptitrated to 5 mg daily based on her resting HR over the following 4 weeks She is started on rivaroxaban 20 mg daily

36 CASE 2 68M Hx HTN, DM2 presents to Olds ED, where you are working. He complains of palpitations and presyncope for ~4 hours, and has never experienced this before afeb HR 130s irreg BP 122/88 O2 98% RA Telemetry and ECG show AF, and you suspect no other acute reversible cause What are your management options? How do you proceed?

37 ACUTE MANAGEMENT Important to remember underlying risk factors, reversible causes First, you need to to determine if they are stable or unstable Unstable > cardioversion Stable Rate control Rhythm control (or Electrical/Pharmacologic cardioversion) CCS Atrial Fibrillation Guidelines Management of Recent-onset Atrial Fibrillation and Flutter in the ED

38 ACUTE MANAGEMENT - RATE CONTROL Drug Dose Risks Metoprolol mg IV bolus over 2 min; up to 3 doses Hypotension, bradycardia Diltiazem 0.25 mg/kg IV bolus over 10 min; repeat at 0.35 mg/kg IV Hypotension, bradycardia Verapamil mg/kg over 2 min Hypotension, bradycardia Digoxin 0.25 mg IV each 2 h; up to 1.5 mg Bradycardia, digitalis toxicity *Calcium-channel blockers should not be used in patients with heart failure or left ventricular dysfunction CCS Atrial Fibrillation Guidelines Management of Recent-onset Atrial Fibrillation and Flutter in the ED

39 ACUTE MANAGEMENT - RATE CONTROL Be aware of the pharmacokinetics of the IV formulations IV rate control should often be a bridge to PO formulations for sustained effect Do not forget anticoagulation

40 ACUTE MANAGEMENT CCS Atrial Fibrillation Guidelines Management of Recent-onset Atrial Fibrillation and Flutter in the ED

41 ACUTE MANAGEMENT - PHARMACOLOGIC RHYTHM CONTROL Drug Dose Efficacy Risks Procainamide (Class IA) Propafenone (Class IC) mg/kg IV over 60 min ++ 5% Hypotension mg PO +++ Hypotension, 1:1 flutter, bradycardia Flecainide (Class IC) mg PO +++ Hypotension, 1:1 flutter, bradycardia Ibutilide (Class III) 1-2 mg IV over min Pretreat with MgSO4 1-2 mg IV % Torsades de pointes Class IC drugs should be used in combination with AV nodal blocking agents (beta-blockers or calcium channel in CCS Atrial Fibrillation Guidelines Management of Recent-onset Atrial Fibrillation and Flutter in the ED

42 CASE 2 REVISITED 68M Hx HTN, DM2 presents to Olds ED, where you are working. He complains of palpitations and presyncope for ~4 hours, and has never experienced this before afeb HR 130s irreg BP 146/92 O2 98% RA Telemetry and ECG show AF, and you suspect no other acute reversible cause

43 CASE 2 REVISITED You decide to use synchronized cardioversion at 200J (sedating with fentanyl and midazolam), and are successful on your first attempt Over the following hours, he does revert back into AF He is discharged on no-anticoagulation, and will follow-up with his Family Physician with the next 2-3 days

44 CASE 2 - IT S NOT OVER! Two years later, again in Olds ED, the same gentleman (now 70M) returns with the same symptoms for the last 3 hours afeb HR 130s irreg BP 148/96 O2 98% RA Telemetry and ECG again show AF You again attempt cardioversion, but are unsuccessful. What now?

45 CASE 2 You administer 5 mg IV of metoprolol. His HR slows to the range, and he does not become hypotense. You administer another 5 mg IV of metoprolol and 25 mg PO, after which his HR drops to ~100. His symptoms resolve You discharge him on metoprolol 25 mg PO BID, and warfarin 5 mg daily with an INR check and GP followup

46 OBJECTIVES Guidelines-based approach to the following: Initial diagnosis and work-up Management as an outpatient Rate control Rationale for rhythm control Anticoagulation (including NOACs) Management in an acute setting

47 Thank you! Any questions?