Atrial Fibrillation Modern Therapies

Size: px

Start display at page:

Download "Atrial Fibrillation Modern Therapies"

Dorcas Loren Barton
7 years ago
Views:

1 Southeast Regional Heart and Vascular Symposium for Primary Care Providers Atrial Fibrillation Modern Therapies Gregg Shander, MD, FACC

2 No Disclosures

3 AF Epidemiology Number of AF patients world-wide estimated at 33.5 million (0.5 % of world s population) Currently there are 5 million new cases worldwide per year and it is expected to increase to over 12 million by 2030 Approximately 5 million cases of AF in the U.S. Lifetime risk of AF in pts > 55y.o. is approx. 25%

4 AF Epidemiology Aging population is the biggest factor for increasing AF prevalence Prevalence of AF 0.16% < 49 y.o. 3.7% y.o. 10% > 80 y.o.

5 CAD Hypertension Obesity Sleep Apnea CHF COPD Renal Failure Comorbidities Associated with AF

6 Patterns of Atrial Fibrillation Paroxysmal < 1 wk, often < 24hrs. Usually terminates spontaneously Persistent > 1wk but < 1yr. Usually requires cardioversion Permanent > 1 yr. Usually refractory to meds and cardioversion

7 Atrial Fibrillation Begets Atrial Fibrillation

8 Action Potential changes with Chronic Atrial Fibrillation

9 Progressive Atrial Fibrosis with Persistent Atrial Fibrillation

10 Land Masses and Eddy Currents

11 Models of Re-entry Atrial Fibrillation

12 Atrial Fibrillation Progression 4-9% of pts advance to Permanent AF within 1 st year 25% will advance to Permanent AF within 5 yrs. Detection is challenging Classic symptoms include palpitations, dizziness, chest pain More subtle symptoms shortness of breath, weakness About 1/3 of pts have symptoms 5-10 yrs before detection of AF

13 Pharmacotherapy for AF Propafenone, Flecainide Class Ic agents. Block Na channel Slows conduction (widens QRS at toxic dosing) Unable to use in sick hearts Sotalol Class III agent. Block K channel Effects repolarization (prolongs QTc interval) Can cause Torsades des Pointes Beta-Blocker slows HR Cleared by kidneys Dofetilide Class III agent, also blocks K channel and lengthens repolarization Does not slow HR Requires a 3 day hospital stay for loading due to risk of pro-arrhythmia (Torsades)

14 Pharmacotherapy for AF Amiodarone Non-Specific alters many channels Dirty-Drug goes throughout the body Side-effects increase over time Not FDA approved for AF Probably our most effective and safest drug in sick hearts Dronaderone Amiodarone-like Initially promising (ATHENA Trial), then warnings about deaths in cardiomyopathy pts with permanent AF (PALLAS Trial) Effectiveness in real-world seemed less than clinical trials

15 Problems with Pharmacotherapy Unable to use in many less healthy patients Cardiomyopathies CAD Renal Insufficiency Bradycardia Often Ineffective. Except for Amiodarone, efficacy less than 40% by one year

16 AFFIRM Trial Mortality Trial 4000 pts Over 65 with at least one risk factor for stroke or early death e.g. CAD,Htn Compared Rate vs Rhythm Control (any A.A.) strategies Results: No significant difference in either mortality or stroke between the two strategies. A trend toward increased mortality with A.A. drugs Conclusion: Rhythm Control is equivalent to Rate Control in terms of mortality

17 Origins of Atrial Fibrillation Ablation

18 AF Ablation Set-Up General Anesthesia, Intubation and mechanical ventilation 6 venous catheters and 1 arterial insertion 2 trans-septal punctures use of intracardiac ultra-sound RF ablation catheter and circular mapping catheter in the left atrium Esophageal temperature probe Delivery of lesions in the left atrium Procedural times of between 2.5 and 4 hrs

19 Potential Complications from AF ablation Groin complications (hematoma, A-V fistula, pseudoaneurysm) Cardiac tamponade 0.5% -3% Stroke 0.5%-1.5% Asymptomatic cerebral emboli 5-10% Pulmonary vein stenosis 1% Phrenic nerve injury 0.5% RF, 11% cryo-ablation Esophageal-atrial fistula 1/ Death 1/1000

20 ICE and Fluoroscopic Images of AF Ablation

21 Radiofrequency lesions around Pulmonary Veins

22 Pulmonary Vein Isolation

23 Thermocool AF Trial 167 pts. 2:1 Ablation to A.A therapy excluding Amiodarone After a 3 month blanking period, data collection of 9 months by transtelephonic monitoring Success = No symptomatic or asymptomatic documented AF episodes Results: 66% success with ablation 16% success with A.A. therapy

24 Smart Touch Catheter Smart Touch Trial Pressure sensitive measured in grams of force If > 80% of lesion delivery time had sufficient force, then efficacy of ablation increased from 66-82%

25 STAR AF 2 Trial Persistent Atrial Fibrillation (76% >6mos) 589 patients, 12 countries Randomised to different ablation strategies PVI vs PVI w/ Linear Ablation vs PVI w CFE f/u 18 mos utilizing ILR Failure = Afib > 30 sec No significant difference between ablation strategies. PVI alone the best at 59% success.

26 Catheter Ablation vs Antiarrhythmic Drug Therapy (CABANA Trial) Determine freedom from AF in Drug (rate or rhythm control) vs ablation in patients with comorbidities or age > 65 Persistent and paroxysmal AF Assess mortality, stroke, hospitalization and cost outcomes

27 Summary (Tell them what you told them) Atrial Fibrillation involves many patients and it s growing It is often progressive, from rare paroxysmal episodes to more persistent or permanent conditions Antiarrhythmic Drugs and cardioversion should be considered in symptomatic patients, but they are often ineffective and limited by patients comorbidities Although labor intensive and associated with some procedural and periprocedural risks, Radiofrequency Ablation can be a safe and effective treatment for symptomatic AF patients in whom A.A. drugs have failed The earlier we see these patients, the more likely we are to have successful outcomes

28 Thank you. Gregg Shander, MD, FACC

32 STARRII Trial

33 Tell them what you re going to tell them Atrial Fibrillation epidemiology Natural history Pharmacologic treatments for AF (Rate vs Rhythm Control) Catheter Ablation for AF What does it look like Trial Data

34 Problems with AFFIRM Trial Erroneous conclusion would be never to use A.A. drugs AFFIRM Trial does not address symptoms in an individual patient Symptoms are the only absolute reason to use a Rhythm Control strategy No indication of improved mortality with any rhythm control strategy No indication of decreased stroke risk. Pt who requires anticoagulation, must still take anticoagulation

DISCLOSURE. Atrial Fibrillation Management An Evidence-based Approach OBJECTIVES BACKGROUND AFFIRM 9/16/2015

DISCLOSURE. Atrial Fibrillation Management An Evidence-based Approach OBJECTIVES BACKGROUND AFFIRM 9/16/2015 Death (%) Mortality (%) 9/16/2015 DISCLOSURE Atrial Fibrillation Management An Evidence-based Approach Jonathon Adams, MD, FHRS Relevant Financial Relationship(s) None Off Label Usage None OBJECTIVES What