ATRIAL FIBRILLATION RATE VS RHYTHM CONTROL NCVH BIRMINGHAM 2014

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Basil Waters
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1 ATRIAL FIBRILLATION RATE VS RHYTHM CONTROL NCVH BIRMINGHAM 2014

2 Facts 4 million or so people have atrial fibrillation 16 billion dollars spent yearly in USA 30% of strokes attributable to AF and AFL 3-5 fold increase risk of stroke on average Most common sustained arrhythmia carried by adults Makes all other problems worse Commonly accompanies Hypertension LV dysfunction Congestive heart failure Diastolic and Systolic Coronary heart disease Rheumatic heart disease Pulmonary embolism COPD More

carried by adults Makes all other problems worse Commonly accompanies Hypertension LV dysfunction Congestive

3 Atrial Fibrillation Disorganized atrial activity Electrical storm Generated from specific areas in the atrial myocardium Can be focal Pulmonary vein origin Becomes more generalized with time Atrial Remodeling occurs Muscle fibers are able to repolarize more quickly, a hallmark of atrial fibrillation Leads to fibrosis in time, and permanency of the arrhythmia Atrial tissue loses contractile properties

Remodeling occurs Muscle fibers are able to repolarize more quickly, a hallmark of atrial

4 Atrial Fibrillation Clinical Consequences Symptoms Palpitations Dyspnea on exertion Fatigue Chest pain Dizzy, syncope(not common) Exercise intolerance Increased urination Strokes Approximately 30% of all strokes in the US preventable 90% come from the left atrium, mostly the appendage Due to loss of contractile properties Ejection of blood from the atrium slows Atrial smoke Atrial thrombus

30% of all strokes in the US preventable 90% come from the left atrium, mostly the appendage Due

5 Atrial Fibrillation and Stroke Risk

6 Atrial Fibrillation Mortality Effect Independent risk factor for mortality AFFIRM 1 presence of SR was associated with reduction in mortality Diamond-CHF 2 SR in those with EF was associated with reduction in mortality Swedish registry 3 272,186 with incidental AF vs 544,344 matched AF free controls Women: 2.15 (<65), 1.72 (65-74), 1.44 (75-85) Men: 1.76 (<65), 1.36 (65-74), 1.24 (75-84) 1: Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management Study Circulation 2004;109(12):1509 2: Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish investigation of arrhythmia and mortality on dofetilide substudy. Circulation 2001;104(3):292 3: All cause mortality in 272,186 patients hospitalized with incident atrial fibrillation , Eur heart J. 2013;34(14):1061

24 (75-84) 1: Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management Study Circulation 2004;109(12):1509 2: Efficacy of

7 Atrial Fibrillation Mortality Effect Framingham Heart Study Ages year follow up Controlled for other comorbidities, well matched controls 1.5% increase in men 1.9% increase in women

8 Atrial Fibrillation Treatment considerations

9 Treatment Goals Prevent stroke Depends on the individualized assessment of stroke risk in a patient CHADS2-VASC (prev CHADS2) May require advanced therapies for prophylaxis ASA VKA, LMWH or unfractionated heparin NOACS Mechanical means for stroke prevention Left atrial appendage occlusion Treat and prevent symptoms Rate control Rhythm Control

$prophylaxis ASA VKA, LMWH or unfractionated heparin NOACS Mechanical means for stroke$

10 Rate Vs Rhythm Control How to choose? Based on symptoms mostly Or, on ongoing damage or impairment of heart function with afib or aflutter. Which is better? Which is safer for the patient?

11 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation Developed in Collaboration with the Society of Thoracic Surgeons January CT, Wann LS, Alpert JS, Calkins H, Cleveland Jr JC, CigarroaJE, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary, Journal of the American College of Cardiology (2014), doi: / j.jacc American College of Cardiology Foundation and American Heart Association

WG, Tchou PJ, Tracy CM, Yancy CW, 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary, Journal of

12 Approach to Selecting Drug Therapy for Ventricular Rate Control Atrial Fibrillation No Other CV Disease Hypertension or HFpEF LV Dysfunction or HF COPD Beta blocker Diltiazem Verapamil Beta blocker Diltiazem Verapamil Beta blocker Digoxin Beta blocker Diltiazem Verapamil Amiodarone

or HF COPD Beta blocker Diltiazem Verapamil Beta blocker Diltiazem

13 What's Missing? Digoxin We always use Dig..its a no brainer right? Multiple observational studies have now cast digoxin in a light of unfavorability for most previous areas of use in AF.

From: Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial Fibrillation: Findings From the TREAT-AF Study J Am Coll Cardiol. 2014;64(7):660-668. doi:10.1016/j.jacc.2014.03.

14 From: Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial Fibrillation: Findings From the TREAT-AF Study J Am Coll Cardiol. 2014;64(7): doi: /j.jacc Figure Legend: The TREAT-AF Study Researching the association of digoxin therapy with mortality in patients with newly diagnosed atrial fibrillation/atrial flutter (AF). CI = confidence interval; HR = hazard ratio; TREAT-AF = The Retrospective Evaluation and Assessment of Therapies in AF. Date of download: 9/6/2014 Copyright The American College of Cardiology. All rights reserved.

060 Figure Legend: The TREAT-AF Study Researching the association of digoxin therapy with mortality in patients with newly diagnosed atrial

15 Strategies for Rhythm Control in Patients with Paroxysmal and persistent AF

16 Case Study 37 year old black female with prior stroke and no other risk factors diagnosed with new onset atrial fibrillation. Feels terrible, heart rate 185 and irregular. Nauseated, dizzy, short of breath, weak. Physical exam unremarkable, not obese, labs and echo normal Anticoagulate: Yes Rate or Rhythm Control: First episode? Would not commit to rhythm control on just the first occasion usually, might be long time till recurrence

Physical exam unremarkable, not obese, labs and echo normal Anticoagulate: Yes Rate or Rhythm Control: First

17 Case 2 84 year old man with longstanding CHF, new onset AF, has been cardioverted, now in NSR. EF 35%, DM, HTN, CAD, class II symptoms on NYHA CHF scale usually. On no meds, lost to follow up. PE: LABS: Gen: shaky, gait unsteady but uses a walker CV: IRR IRR Lungs: CTA Ext: no edema HCT:29 Cr: 1.5, CrCL 48 TSH: 1.3

EF 35%, DM, HTN, CAD, class II symptoms on NYHA CHF scale usually.

18 Case 2, Cont. Anticoagulate: CHADS2-VASC? Age 2, EF 1, HTN 1, DM 1, CAD - 1 Total score: 6 No! No No No! Fall risk and risk of potential bleeding given the low hematocrit, may be a great candidate for Watchman if it ever appears. Rate vs Rhythm Control: If he felt terrible in afib if rate controlled, then he is a great candidate for rhythm control. Antiarrhythmic of choice? Amiodarone (Dofetilide if renal function normal)

19 In Summary AF is common, expensive, carries much morbidity and mortality, is the leading cause of preventable stroke, exacerbates any cardiac co-morbidity Cuts across boundaries of primary care and specialty care and requires both to have a grasp of how to treat. The treatment emphasizes reducing stroke and symptoms, with a premium on avoiding the wrong medication for your patient based on safety first, then efficacy Has interventional treatment that is becoming more successful and mainstream. Is often a lifelong problem

20 Q and A

ATRIAL FIBRILLATION: Scope of the Problem. October 2015

ATRIAL FIBRILLATION: Scope of the Problem October 2015 Purpose of the Presentation Review the worldwide incidence and prognosis associated with atrial fibrillation (AF) Identify the types of AF, clinical