2/22/2011. Stacy Dawkins, MPAS, PA-C IAPA Feb Fest 2011 Disclosures: None

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1 Stacy Dawkins, MPAS, PA-C IAPA Feb Fest 2011 Disclosures: None 1. Identify and describe therapy options for atrial fibrillation 2. Utilization of the CHADS 2 scoring system in decision making for atrial fibrillation 3. Recognize and understand medications for rate control and the most commonly used antiarrhythmics 4. Determination of the best anticoagulant therapy based on patient risk factors and co-mobidities 1. Incidence increases with age 1 (esp. >60) 2. Lifetime risk of developing A-fib is almost 25% in people over A-fib affects 2.3 million people in the US currently, and, with anticipated growth of the elderly population, the number is projected to increase to 3.3 million by 2020, and possibly 5.6 million by A 2010 study by the Mayo Clinic showed that 40% of their participants did not know that they had A-fib 1

2 1. Paroxsysmal A-fib - lasts < 7 days, converts spontaneously without intervention 3 2. Persistent A-fib - can be pharmacologically or electrically converted, but not spontaneous 3 3. Permanent A-fib - chronic, cannot be converted to normal sinus rhythm (NSR) 3 *A-fib has an atrial rate of BPM, but ventricular contraction is much less because of variable transmission to the ventricles; therefore, A-fib can be fast or slow Structural heart disease (HTN, CAD, cardiomyopathies (including EtOH induced), CHF, atrial septal defect) 1 2. Medications (Theophylline, Beta- Adrenergics, like Albuterol) 1 3. Disease states (Hyperthyroidism, COPD, active lung infections, pericarditis, s/p cardiac surgery) 1 4. Familial 1 5. Lone A-fib - without a structural cause 1 1. Chest pain 2. Dyspnea 3. Dizziness or lightheadedness 4. Palpitations 5. Syncope 6. Weakness/Fatigue 7. Hemodynamic compromise 8. Asymptomatic * If your patient presents with any of these symptoms, then check an ECG in the office 2

3 1. Framingham data showed that people with A-fib are almost 5 times more likely to have a CVA than persons without A-fib 4 2. Why does this happen? Changes of atrial myocardium 5 Left atrial appendage (LAA) enlargement 6,7 Velocity of flow in atria and LAA 7,8 Lower ejection fraction (EF: normal >55-60%) 9 *All of these lead to increased risk of thrombus formation! We must protect the brain! 1. Protect the brain with: a. Aspirin low risk patients b. Clopidogrel (Plavix) often used with aspirin in patients who cannot take Warfarin(based on ACTIVE-A trial, NEJM, 2009) c. Dabigatran (Pradaxa) intermediate to high risk patients with non-valvular A-fib d. Warfarin (Coumadin) intermediate to high risk patients with valvular involvement or other co-morbidities 1. Beta Blockers 2. Calcium channel blockers (Diltiazem, Verapamil) 3. Digoxin * Definition of rate control in recent studies like the RACE II trial as follows: * Strict control < 80 at rest, <110 with moderate exercise * Lenient control < 110 at rest 3

4 1. Direct current (DC) cardioversion 2. Pharmacological cardioversion a. Ibutilide/Corvert (IV only) b. Amiodarone (Cordarone, Pacerone) c. Dronedarone (Multaq) d. Sotalol (Betapace) e. Propafenone (Rythmol) f. Dofetilide (Tikosyn) g. Flecanide (Tambocor) 3. Surgical options HPI: Presented to ER with palpitations while writing on a chalkboard in class one day prior to admission. + Dizziness, dyspnea, near-syncope, mid-sternal sharp chest pain with radiation to mid-thoracic region. Saw her PCP today, referred to ER after ECG showed tachycardia PMH: HTN, hypothyroidism, UC, pernicious anemia, no FHx of premature CAD/SCD, no tobacco, no EtOH Meds: Diovan HCT 80/12.5, Synthroid 125mcg PE: BP 152/70, HR 145, RR 20, Heart: Irregularly irregular rhythm with tachycardia no murmur, gallop, rub, click. 4

5 1. Diagnosis: New onset A-fib with rapid ventricular response (RVR) 2. First, we need to slow her down to help her symptoms and consider cardioversion since she has been in A-fib for < 48 hours. 3. She was given an IV Diltiazem bolus and converted to NSR spontaneously 1. A-fib present for < 48 hours 1 2. Left atrial thrombus has been ruled out with transesophageal echo 1 3. Anticoagulated with Warfarin and an INR of 2-3 for at least 3 weeks prior and at least 4 weeks after cardioversion 1 *If >48 hours of A-fib, patients have a 2-5% chance of embolic CVA with DC or pharmacological cardioversion 1 1. CHADS 2 - Point-based risk assessment tool that derived from a committee from ACC and AHA who looked at a 2001 study from JAMA and developed the 2006 A-fib guidelines to assess risks for CVA in people with A-fib C : Recent CHF (EF: <40%) = 1 point H : Hx of Hypertension (HTN) = 1 point A : Age 75 = 1 point D : Diabetes mellitus = 1 point S 2 : Previous Stroke or TIA = 2 points 5

6 Risk Assessment: Score of 0 = Low risk for CVA 1. Score of 1-2 = Intermediate risk for CVA 2. Score of 3 or more = high risk for CVA Anticoagulant recommended: 1. Score of 0 = ASA alone (81-325mg) 2. Score of 1 = ASA or Warfarin 3. Score of 2 or more = Warfarin What is ES s CHADS 2 score? Pt. has hx of HTN = 1, or intermediate risk 1. Can be placed on Diltiazem or Beta Blocker PO with Omega-3-acid ethyl esters (Lovaza) 4,000mg daily with NSR and paroxsysmal A-fib 2. Placed on Aspirin 81mg daily with CHADS 2 score, ability to know symptoms and paroxsysmal A-fib 3. Obtained Echo/doppler, event monitor and TSH as OP HPI: Presented to ER after seeing her new PCP to establish care, found to be in A-fib with RVR by ECG. + Dizziness only, she did NOT have palpitations or know her heart was out of rhythm PMH: HTN, hypothyroidism, UC, pernicious anemia, no FHx of premature CAD/SCD, no tobacco, no EtOH Meds: Diovan HCT 80/12.5, Synthroid 125mcg, ASA 81mg daily - Pt. had self-discontinued her Toprol XL and Omega-3-acids PE: BP 134/72, HR 156, RR 20, Heart: Irregularly irregular rhythm with tachycardia without murmur, gallop, rub, click. 6

7 1. Diagnosis: Persistent vs. Permanent A-fib with RVR 2. Diltiazem again? 3. Need Rate Control - Medical decision making a. IV Diltiazem changed to PO Diltiazem b. Beta-Blocker added Carvedilol c. Omega-3-acid ethyl esters (Lovaza) restarted 1. CHADS 2 score = 1 2. She declined TEE; thus, we could not consider cardioversion of any kind 3. Protect the brain a. Enoxaparin (Lovenox) or IV Heparin b. Aspirin? c. Dabigaran (Pradaxa) 7

8 1. Dosage is 150mg BID, direct thrombin inhibitor 2. Approved to reduce the risk of stroke and systemic embolism in non-valvular A-fib 3. RE-LY trial 9/09 in NEJM Dabigatran administered at a dose of 150mg BID, as compared with Warfarin, was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage Dyspepsia 5. ES started on Dabigatran (Pradaxa) after GI consult HPI: Presented to ER with volume overload including peripheral and central edema, progressive dyspnea, but no palpitations, dizziness, chest pain PMH: CAD with Hx of CABG, Type II DM, HTN, HLP, Hx of CHF (EF: 35%), Paroxsysmal A-fib, VHD (mild MR), + Premature CAD in mother, former tobacco quitting 25 yrs ago, no EtOH Meds: Metoprolol 25mg BID, Losartan 50mg, Doxazosin 4mg, Furosemide 40mg, Simvastatin 40mg, Glucophage 1000mg BID, Lantus 80 units PE: BP 191/120, HR 91, RR 14, Heart: Irregularly irregular rhythm with II/VI systolic murmur without gallop, rub, click, Lung: Bibasilar rales, Extremities: 1+ bil LE pitting edema 8

9 1. Diagnosis: Persistent vs. Permanent A-fib with Acute systolic CHF Exacerbation 2. Rate or Rhythm control? Is he rate controlled currently? Is he on anything for rate control? Is he in normal sinus rhythm? 3. We need Rhythm management 1. Amiodarone (Cordarone, Pacerone) a % effective at preventing recurrent atrial fibrillation if the patient converts 1 b. Can be toxic to thyroid, lungs, and skin - Check TSH, CXR at least annually 2. Dronedarone (Multaq) a. Similar to Amiodarone, but less effective, less toxic effects, NOT for CHF patients as can exacerbate CHF b. New concerns about liver toxicity 3. Sotalol (Betapace) a. Properties of a beta blocker b. Can cause Torsade de Pointes, new VT/VF so must initiate in hospital for monitoring and dose changes 4. Propafenone (Rythmol) a. Approved for A-Fib in patients without CAD or structural heart disease b. Avoid in asthma and COPD patients because of beta-adrenergic blocking effect 9

10 5. Dofetilide (Tikosyn) a. Like Sotalol, needs hospital monitoring for initiation and dose changes b. Several contraindications and cautions for use 6. Flecanide (Tambocor) a. Approved for patients without structural heart disease or CAD b. Can cause lengthening of the QT interval and VT 1. Calculate CHADS 2 score C: Hx of CHF = 1 H: Hx of HTN = 1 A: Age 76 ( 75) = 1 D: Has Type II DM = 1 S 2 : No Hx of CVA/TIA = 0 Total = 4 or HIGH risk for CVA 10

11 1. Do we know how long he has been in A- fib? 2. How do we protect his brain? a. High risk per CHADS 2 b. History of VHD, so he cannot use Dabigatran Plan: Initiate Enoxaparin (Lovenox) high dose or IV Heparin while hospitalized Initiate Warfarin (Coumadin) with goal INR of 2-3, stop #1 above when INR therapeutic Consider Amiodarone if heartrate uncontrolled with Hx of CHF Continue Metoprolol for rate control(approved Beta Blocker in CHF) HPI: Presented to office after experiencing palpitations, dyspnea, and near-syncope while refereeing a high school football game. He has recurrent problems with persistent A- fib (4 th episode) and feels that this is keeping him from a normal life. He is frustrated about medication options, and has had problems with medications in the past. He has been hesitant to pursue surgical options. PMH: A-flutter, persistent A-fib, HTN, HLP, amiodaroneinduced hyperthyroidism - Premature CAD but mother had A- fib and CVA at 78 causing her death, no EtOH or Tobacco Meds: Carvedilol 25mg BID, Digoxin.125mg, Omega-3 4 grams daily, Warfarin 10mg daily, Niaspan 500mg, Altace 5mg BID, Zocor 20mg. PE: BP 124/76, HR 55, RR 12, Heart: Regular rate and rhythm without murmur, gallop, rub, click, remainder of exam negative. 11

12 1. Consider Radiofrequency (RF) ablation or RF atrioventricular node (AVN) ablation with permanent pacemaker (PPM) placement * RF ablation good for common types of A-fib/flutter 1 (83-87% success rate per 2010 study from the British Journal of Cardiology) * RF AVN ablation with PPM difficult patients, commits patient to lifelong PPM dependence and Warfarin therapy (>90% success rate at lifestyle improvement) 2. Surgical Options by Cardiothoracic surgery * Wolf Mini-Maze epicardial RF ablation for pulmonary vein isolation with mapping of ganglionated plexi and ablation, excision of LAA through limited bilateral thoracotomy incisions, done with an Electrophysiologist (67-91% success rate) * Maze Multiple incisions made in atria to prevent reentry circuits at the time of cardiac surgery through a sternal incision (90-97% success rate) 12

13 Very active 70 y-o male, and he did not wish to have PPM placed; therefore, he chose RF ablation. He underwent two ablations, one for A-flutter, then for A-fib which became more persistent s/p initial ablation. Unfortunately, this last ablation was not successful, so he underwent the MAZE procedure with excision of the LAA. 1. Do NOT forget to protect the brain 2. Calculate the CHADS 2 score on every patient to assess stroke risk and decide how best to protect the brain 3. Check an ECG in the office if your patient is symptomatic (or check a baseline ECG if you have not already) 4. Rate control drugs (ie. Beta and Calcium Channel Blockers) do not convert patients to NSR 5. Refer to Cardiology when you need help Thank You! 13

14 1. Chizner, MD, Michael A. Clinical Cardiology Made Rediculously Simple, Third Edition. MedMaster Inc., Miami, FL, Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke preventions: The AnTicoagulation and Risk factors In Atrial Fibrillation (ATRIA) study. JAMA National Heart Lung and Blood Institute. Atrial Fibrillation. June, Wolf, PA, Abbott RD, Kannel, WB. Atrial fibrilaltion as an independent risk factor for stroke: The Framingham Study. Stroke Ausma J, van der Velden HMW, Lenders, MH, et al. Reverse structural and gap-junctional remodeling after prolonged atrial fibrillation in the goat. Circulation Shirania, J, Alaeddini, J. Structural remodeling of the left atrial appendage in patients with chronic non-valvular atrial fibrillation. Cardiovascular Pathololgy Manning, WJ, Silverman, DI. Atrial anatomy and function postcardioversion; insights from TTE and TEE. Progressive Cardiovascular Disease Sperry, JL, Deming, CB, Bian, C, et al. Wall tension is a potent negative regulator of in vivo thrombomodulin expression. Circ Res Tsai, LM, Lin, LF, Teng, JK, Chen, JH. Prevalence and clinical significance of left atrial thrombus in nonreheumatic atrial fibrillation. International Journal of Cardiology Connolly, SJ, et al. Dabigatran versus Warfarin in patients with atrial fibrillation. NEJM