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1 2:15 3 pm Managing Arrhythmias in Primary Care Presenter Disclosure Information The following relationships exist related to this presentation: Raul Mitrani, MD, FACC, FHRS: Speakers Bureau for Medtronic. SPEAKER Raul Mitrani, MD, FACC, FHRS Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Learning Objectives Managing Arrhythmias in Primary Care Raul D. Mitrani, MD, FACC, FHRS Director, Clinical Cardiac Electrophysiology Associate Professor of Medicine University of Miami, Miller School of Medicine 1. Discuss the best approach to diagnosis and treatment of newly diagnosed atrial fibrillation and other atrial arrhythmias 2. Review the pathophysiology of supraventricular tachycardia, atrial flutter and atrial fibrillation 3. Identify the indications and efficacy for catheter ablation 4. Incorporate risk factor modification in patients with atrial fibrillation Main Mechanisms and Typical Electrocardiographic Recordings of Supraventricular Tachycardia Autonomic Tone dependent AV nodal dependent AV Node re-entry AV re-entry Some atrial tachycardias atrial flutters and other atrial macroreentry circuits less likely AVNRT = Atrioventricular nodal reentrant tachycardia AVRT = Atrioventricular reentrant tachycardia SVT- Key Points REGULAR SVT Initial diagnosis Focus on ventricular response, regularity, type of onset (gradual or abrupt) Gradual onset Sinus tachycardia, some ectopic atrial tachycardias Abrupt onset AVNRT, atrial flutter, AVRT, some atrial tachycardias Termination With adenosine Delacretaz, E. N Engl J Med 26;354:

2 Impact of SVT Symptoms Dizziness, palpitations, syncope, chest pain, anxiety, neck pounding Patients often present to ER and can have multiple episodes One study showed that 67% of patients with unrecognized SVT fulfilled criteria for panic disorder Patients may limit exercise to avoid the symptoms Treatment - Class I recommendations from ACC/AHA EP Study with catheter ablation Highly successful Low risk for serious complications Curative procedure in many patients Beta blockers, diltiazem, verapamil Instruct patients on how to perform vagal maneuvers Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Arch Intern Med. 1997;157: Guideline for the Management of Adult Patients With SVT, Heart Rhythm, hrthm

3 Classification of atrial fibrillation Modifiable Risk Factors PAROXYSMAL >3 sec, < 7 days First Detected PERSISTENT Nonself terminating Hypertension Obesity Sleep Apnea Alcohol Long standing Persistent (> 1 year)

4 Pathophysiology of atrial fibrillation Refractory changes Fibrosis, worsening CHF Hypertension CHF, CAD, MR,MS, AS, AI LA pressure/volume overload LA REMODELLING ATRIAL FIBRILLATION Inflammation Fibrosis/Left atrial enlargement PV Triggers (Lone Afib) Reversible causes of atrial fibrillation Hyperthyroidism- < 2% Mainly in new onset atrial fibrillation Drug induced hyperthyroidism can worsen/exacerbate episodes of afib in patients with paroxysmal afib Alcohol Pericarditis/myocarditis Post-op CT surgical Acute MI Association with WPW/ other SVTs Impact of Atrial Fibrillation on Mortality Framingham Study AFFIRM Survival by Actual Rhythm Dead (%) Years Old Men AF Women AF Men no AF Women no AF Years Old Sinus Warfarin AAD Age (per year) CHF CAD P< Follow-up (yr) Follow-up (yr) Higher survival Hazard ratio Lower survival Benjamin et al. Circulation 98:946, 1998 AFFIRM Investigators: Circ 19:159, 24 Rate vs Rhythm Drugs Acute Rate Control Rate Control Beta Blockers Diltiazem, Verapamil Digoxin Amiodarone Rhythm Control Drugs Amiodarone Sotalol Flecainide/Propafenone Dronedarone Dofetilide Quinidine Target Mean rate < 1 to 11 Usually AFIB with RVR reflects enhanced sympathetic tone from underlying comorbidities COPD, CHF, Sepsis

5 Risks of antiarrhythmic drug therapy Toxic and other side effects Interactions with other medications Pro-arrhythmic actions Randomized Studies of Anti-arrhythmic Drugs vs. Catheter Ablation (RF) % 1 P<.1 P<.1 P<.1 Drug n=26 n=54 Ablation 8 4 n=13 n=38 n=21 n=4 n=4 n=57 2 n=6 n=4 RAAFT 1 CACAF 2 APAF 3 A4 4 ORAL 5 1 JAMA 293:2634, 25; 2 Eur Heart J 27:216, 26; 3 JACC 48:234, 26; 4 Circ 118:2498, 28 5, 26; 5 NEJM 354:967, 261 Outcomes of Afib ablation Ablation Success: How Do You Get There? Improvement in quality of life Fewer episodes of atrial fibrillation Class I indication for ablation in patients with symptomatic PAF who failed antiarrhythmic drugs AF ablation is not an alternative to anticoagulation Paroxysmal Persist/chronic PV isolation Non- PV foci Linear abl Redo ?? Packer et al, 27 %

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