Atrial Fibrillation Management for Presented by Dr. Marcel Fournier

Transcription

1 Atrial Fibrillation Management for 2016 Presented by Dr. Marcel Fournier

2 Disclosure No conflict of interest to declare

3 New CCS Algorithm

4 New Rate/Rhythm Algorithm

5 Dr. YD, Age 42, Family Practitioner Last evening he was out celebrating the marriage of his receptionist and consumed about 12 ounces of Johnny Walker Black label. He went home by taxi, slept poorly and realized this morning about 6:00 am that his heart rate was rapid and pulse irregular. He has a mild bitemporal headache and is driven to the ED by his wife. He has been well, no known hypertension, DM, heart disease, TIA/stroke and no known arrhythmias although he does have mild palpitations from time to time. No COPD or asthma. In ED: no chest pain, mild SOB, slightly sweaty. HR 140, irregularly irregular, BP 140/90, JVD 4 cm, Chest clear. ECG shows AF, rate 140.

6 Dr. YD, Age 42, Family Practitioner How will you manage his rhythm? 1. Electrical cardioversion ( j) in ED as soon as it can be done. 2. IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Home on po metoprolol mg bid if AF persists. 3. IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Add propofenone 450 mg po about minutes after first dose of metoprolol if AF persists. 4. IV metoprolol 5 mg, repeated Q 5 min up to 3 times if rate remains above 110. Electrical cardioversion if AF persists. 5. Digoxin 0.25 mg IV, repeat at 1 hour intervals up to 4 doses if AF persists.

7 Dr. YD, Age 42, Family Practitioner How will you reduce his risk of stroke if you decide to cardiovert him? 1. IV LMWH or a NOAC po about 1 hour prior to any cardioversion attempt. 2. IV LMWH or a NOAC po about 1 hour prior to electrical cardioversion, but not required for pharmacologic cardioversion. 3. No anticoagulant required pre cardioversion attempt. 4. Start dabigatran 150 mg bid and have him return for cardioversion after 3 weeks of dabigatran.

8 Management of AF in the ED Recommendations Low Risk 1. Clear onset <48 hours, or 2. Therapeutic OAC 3 wks Immediate Risk for Stroke? Is Patient Stable? YES High Risk** No therapeutic OAC 3 weeks and one of: 1. Onset >48 hours or unknown, or 2. Stroke/TIA <6 months or 3. Mechanical or rheumatic valve disease. NO Unstable AF causing: 1. Hypotension, or 2. Cardiac ischemia, or 3. Pulmonary edema Pharmacological or electrical CV at J (Immediate anticoagulation in ED before CV not required) * Therapeutic OAC for 3 weeks before outpatient CV Rate-control Trans-esophageal echocardiography (TEE) guided CV Consider urgent electrical CV if rate control not effective Antithrombotic therapy -Initiate OAC upon discharge from ED (or continue current OAC) if age 65 or CHADS 2 1 -Otherwise, initiate ASA if CAD or vascular disease -Early follow-up to review long-term OAC Antithrombotic therapy - Continue OAC for 4 weeks after CV - Early follow-up to review long-term OAC Antithrombotic therapy - Initiate immediate OAC* in ED and continue for 4 weeks - Early follow-up to review long-term OAC Antithrombotic therapy - Initiate immediate OAC* in ED and continue for 4 weeks if any high risk ** features present - Early follow-up to review long-term OAC * Immediate OAC = a dose of OAC should be given just prior to cardioversion - either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin with bridging to warfarin if a NOAC is contraindicated. Emergency Management of AF

9 Dr. YD, Age 42, Family Practitioner How will you reduce his risk of stroke post discharge from Ed? 1. If AF persists, he requires maintenance ASA 81 mg daily at least until follow-up at 1 month. 2. Whether AF persists or resolves, he requires maintenance ASA 81 mg at least until follow-up at 1 month. 3. If AF persists, he requires maintenance OAC at least until follow-up at 1 month. 4. Whether AF persists or resolves, he requires maintenance OAC at least until follow-up at 1 month. 5. Whether AF persists or resolves, he requires no maintenance antithrombotic therapy.

10 A guidelines based approach to AF management Mrs. BB, a 77 year old lady has hypertension, otherwise well Lives alone, has a dog On Ramipril 10 mg and bisoprolol 5 mg a day for hypertension 5 ft 5 in, 190lbs. Comes to the office for routine BP follow-up

11 Pulse rate 85/min, irregular BP 145/95, repeated X 3 No murmurs, no signs CHF Says she feels well On closer questioning, she walks the dog around the block; she used to walk to the park, 2-3 kms away, but no longer feels like it EKG shows AF, otherwise normal, rate 88/min

12 What next? Why does she have AF? 1. Thyroid 2. Hypertension 3. Sleep apnea 4. Ethanol

13 SAF class 2-3 on detailed discussion Choices: increase beta blocker attempt to restore sinus rhythm CHADS = 2 (CHADSVaSC 4) OAC for 3-4 weeks Electrical Cardioversion

14 Major Goals of AF/AFL Arrhythmia Management Identify and treat underlying structural heart disease and other predisposing conditions Relieve symptoms Improve functional capacity/quality of life Reduce morbidity/mortality associated with AF/AFL Prevent tachycardia-induced cardiomyopathy Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL Prevent stroke or systemic thromboembolism Recommendations We recommend that the goals of ventricular rate control should be to improve symptoms and clinical outcomes which are attributable to excessive ventricular rates. (Strong Recommendation, Low Quality Evidence) We recommend that the goals of rhythm control therapy should be to improve patient symptoms and clinical outcomes, and that these do not necessarily imply the elimination of all AF. (Strong Recommendation, Moderate Quality Evidence)

15 Rate vs Rhythm Control for Patients with Symptomatic AF SYMPTOMATIC AF Special circumstances in which to consider early rhythm control: Highly symptomatic Multiple recurrences Extreme impairment in QOL Arrhythmia-induced cardiomyopathy ATTEMPT RATE CONTROL Beta-blocker Calcium channel blocker SYMPTOMS RESOLVE NO YES CONTINUE RATE CONTROL MODIFY RATE CONTROL - CONSIDER RHYTHM CONTROL Low burden recurrence Paroxysmal AF High burden recurrence Persistent AF Consider cardioversion Pill in pocket antiarrhythmic therapy Maintenance antiarrhythmic therapy Symptoms improve, but AF recurs Symptoms improve, and patient maintains sinus rhythm Symptoms don t change in sinus rhythm and AF recurs Catheter ablation Observe. If AF recurs, determine if symptomatic

16 Rhythm Management Recommendations We recommend the optimal treatment of precipitating or reversible predisposing conditions of AF prior to attempts to restore or maintain sinus rhythm (Strong Recommendation, Low Quality Evidence). We recommend a rhythm-control strategy for patients with AF or AFL who remain symptomatic with rate-control therapy or in whom rate-control therapy is unlikely to control symptoms (Strong Recommendation, Moderate Quality Evidence). We recommend that the goal of rhythm-control therapy should be improvement in patient symptoms and clinical outcomes, and not necessarily the elimination of all AF (Strong Recommendation, Moderate Quality Evidence). We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy for patients with recurrent AF in whom long-term rhythm control is desired (see Figures) (Strong Recommendation, Moderate Quality Evidence). We recommend intermittent antiarrhythmic drug therapy ( pill in the pocket ) in symptomatic patients with infrequent, longer-lasting episodes of AF or AFL as an alternative to daily antiarrhythmic therapy (Strong Recommendation, Moderate Quality Evidence). We recommend that oral antiarrhythmic drug therapy should be avoided in patients with AF or AFL and advanced sinus or AV nodal disease unless the patient has a pacemaker or implantable defibrillator (Strong Recommendation, Low Quality Evidence).

17 Dr. Fred Brown, a GP colleague, asks for your advice about Mr. MB, Age 67 Heart skipping beats and racing, especially on exertion 2 weeks prior to GP visit Previously well, active, no significant limitations No hypertension, DM, CHF, no meds HR 100 irreg, BP 135/85 HS normal, no murmurs or gallops, JVP just visible at 45

18 Dr. Fred Brown, a GP colleague, asks for your advice about Mr. MB, Age 67 (cont d) Hgb 145, Glucose 5.4, Cr 1.0 (egfr 110) EKG AF 95/min Echo unremarkable (LA 4.0, LV 5.0, EF 55%, no LVH) Dr. Brown started him on atenolol 50 mg qam and symptoms are much improved

19 Mr. MB, Age 67 yr, 1 week post atenolol 50 mg qam

20 How would you treat him to reduce his risk of stroke? 1. No antithrombotic therapy? 2. ASA 81 mg/day? 3. OAC?

21 What is Mr. MB s CHADS 2 score? What is his annual risk of stroke? %? %? %? %?

22 Risk Factor Congestive Heart Failure Score Hypertension 1 Age 75 1 Diabetes Mellitus 1 Stroke/TIA/ Thromboembolism Maximum Score Stroke rate/ 100 patient yr % CHADS 2

23 For Mr. MB, age 67, the GP is asking: If I prescribe an OAC, which should I choose? 1. Warfarin to achieve INR 2-3? 2. Rivaroxaban 20 mg daily? 3. Dabigatran 150 mg bid or Dabigatran 110 mg bid? 4. Apixaban 5 mg bid? 5. Any of 2, 3 or 4, although not all are equivalent?

24 A guidelines based approach to AF management 67 year old male is scheduled for surgery Pre-op consult regarding OAC management Past history includes 2 years of auto-ratecontrolled persistent AF, controlled HT, controlled type II diabetes, prior MI, NYHA class II CHF, no angina, otherwise well On irbesartan / HCTZ 300 mg / 25 mg OD, insulin, warfarin (INR ) Cannot take a beta blocker as heart rate slow

25 A guidelines based approach to AF management Stroke risk considerations: - CHADS 2 score = 3; CHA 2 DS 2 -VASc = 5 - no mechanical heart valve - no rheumatic heart disease Bleeding risk considerations: - HASBLED score = 1 No AT-Rx: stroke = 10.5%/yr: major bleed = 3.1%/yr On warfarin: stroke = 3.8%/yr: major bleed = 6.7%/yr LaHaye SA et al: Eur J Cardiol 33: , 2012 (

26 Peri-Procedure/Anticoagulation Management Recommendation We suggest that interruption of anticoagulant therapy in a patient with AF/AFL is not necessary for most procedures with a very low risk of bleeding (Conditional Recommendation, Low Quality Evidence), including cardiac device implantation (pacemaker or implantable defibrillator) (Conditional Recommendation, High Quality Evidence) Other very low risk of bleeding procedures include most dental procedures, anterior chamber eye surgery, most dermatologic procedures.

27 Peri-Procedure/Anticoagulation Management - Recommendation Recommendation We recommend that interruption of anticoagulant therapy in a patient with AF or AFL will be necessary for most procedures with an intermediate or high risk of major bleeding. (Strong Recommendation, Low Quality Evidence) When a decision to interrupt warfarin therapy for an invasive procedure has been made for a patient with AF/AFL, we suggest that bridging therapy with LMWH or UFH be instituted in a patient at high risk of thromboembolic events (CHADS 2 3, mechanical heart valve, stroke or TIA within 3 months, rheumatic heart disease). (Conditional Recommendation, Low Quality Evidence)

28 A guidelines based approach to AF management In patients at high risk of thromboembolic events it is customary to use bridging LMWH or UFH heparin during warfarin withdrawal for an invasive procedure. The wisdom of this practice has been questioned by a meta-analysis of 33 observational trials and one RCT reporting that bridging therapy is associated with: an increase in major bleeding (13.1% vs 3.4%, p<0.0001) no reduction in thromboembolic events (0.9% vs 0.6%) Ongoing RCTs PERIOP-2 and BRIDGE Siegel D et al. Circulation 126:1630-9, 2012

29 Thoracotomy accomplished without complications after warfarin withdrawal and LMWH bridging. The lung mass turns out to be benign. Patient switched to apixaban 5 mg bid at his request. One year later planned for knee replacement. egfr = 85 ml/min/m 2 For this patient preparing for a new knee would: 1. stop apixaban 5 days; heparin bridging 2. stop apixaban 2 days; no heparin bridging 3. switch to warfarin then do as before

30 A guidelines based approach to AF management Days of withdrawal prior to high bleeding risk procedure egfr ml/min/m 2 apixaban dabigatran rivaroxaban < 30* Focused Update CCS AF Guidelines Can J Cardiol (in press)

31 Due to the rapid offset and onset kinetics of the current NOACs, bridging LMWH or UFH therapy is only required if the period of withdrawal is longer than that recommended. Assuming haemostasis, after the new knee I would: 1. restart apixaban 2.5 mg bid on PO day 2 2. restart apixaban 5 mg bid on PO day 2 3. restart apixaban 5 mg daily on PO day 3

32 Due to the rapid offset and onset kinetics of the current NOACs, bridging LMWH or UFH therapy is only required if the period of withdrawal is longer than that recommended. Assuming haemostasis, after the new knee I would: 1. restart apixaban 2.5 mg bid on PO day 2 2. restart apixaban 5 mg bid on PO day 2 3. restart apixaban 5 mg daily on PO day 3 Correct! Knee replacement is intermediate risk of bleeding procedure. Recognizing that once a NOAC is started, anticoagulation is (at least transiently) obtained the same day, an optimal balance of risk of post-op bleeding versus risk of thromboembolic event suggests restarting the NOAC 72 hours after this surgery.

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