Atrial Fibrillation 2012: Latest Approaches to Diagnosis, Treatment, and Stroke Prevention

Transcription

1 Atrial Fibrillation 2012: Latest Approaches to Diagnosis, Treatment, and Stroke Prevention Michael G. Clark, PA-C, MPAS, Ph.D., AACC Fisher Cardiology and Electrophysiology Bedford, Texas

2 Disclosures Speakers Bureau Abbott Astra-Zeneka Gilead

3 Objectives At the completion of this presentation the provider will be able to: Describe common etiologies for the development of atrial fibrillation Discuss recent evidence based developments in the diagnosis and treatment of atrial fibrillation. Apply pharmacologic therapeutic options for treatment of atrial fibrillation and prevention of stroke in the primary care setting. Describe non-pharmacologic options for treatment of atrial fibrillation.

4 Case I A 76 year old male with a history of HTN and chronic stable angina presents to the clinic with sudden onset of dizziness and dyspnea. This occurred several hours prior with no change in medications, physical stress or any other factors. He has been well and active, functioning at NYHA Class I. He exercises four times weekly for 30 minutes without difficulty. His angina has been minimal and not active for the past three months. Medications are enalapril 10mg BID, ASA 325 daily, and NTG sublinqual prn. On examination, BP 148/78, pulse 108 and irregular. He has a soft right carotid bruit, no JVD, and clear lungs. Heart is rapid and irregular with a soft systolic outflow murmur in the second interspace right. Abdomen is benign. There are good peripheral pulses and no edema.

5 Case I J Am Coll Cardiol. 2011;57(11):e101-e198.doi: /j.jacc

6 You diagnose Persistent Atrial Fibrillation. Which of the following initial therapeutic approaches is least appropriate at this time? A. Addition of Atenolol B. Initiate oral anticoagulation C. Emergent cardioversion D. Obtain a 48 hour holter

7 You diagnose Persistent Atrial Fibrillation. Which of the following initial therapeutic approaches is least appropriate at this time? A. Addition of Atenolol B. Initiate oral anticoagulation C. Emergent cardioversion D. Obtain a 48 hour holter

8 Definition Atrial fibrillation (AF) is an atrial/supraventricular tachyarrhythmia characterised by predominantly uncoordinated atrial activation with consequent deterioration of atrial mechanical function An irregularly irregular rhythm with no discernable P waves Small irregular deviations of the baseline are called f waves these may be coarse or fine The conduction to the ventricle may range from bradycardia to severe tachycardia

9 Heartdiseasessymptoms.net Atrial Fibrillation

10 Types of Atrial Fibrillation Lone : no underlying heart dysfunction or risk factors, under age 60 Recurrent: more than two episodes observed Paroxysmal: spontaneous conversion to sinus Typically don t last > 48 hours Persistent: lasting greater than 7 days Permanent: lasting 1 year or more with failed attempts at cardioversion Non-Valvular AFib No history of rheumatic mitral valve disease, prosthetic valve replacement or valve repair J Am Coll Cardiol. 2011;57(11):e101-e198.doi: /j.jacc

11 Epidemiology AF is the most common cardiac tachy-arrhythmia in the United States AF is a significant risk factor for morbidity and mortality Hemodynamic Impairment Thromboembolic Risk Co-Morbidities AF incidence and prevalence increase with increasing age. J Am Coll Cardiol. 2011;57(11):e101-e198. doi: /j.jacc

12 Epidemiology Found in 1% of population over 60, and 6% in population over 70 (Nearly 2.7 million Americans) Somewhat more common in men than women More common in white then African-Americans With coronary disease in age group>70, incidence is 10% Heart Disease and Stroke Statistics-2010 Update AHA. Circulation. 2010:121:e91

13 AFib Hospitalizations

14 Etiology Ischemic Heart Disease Chronic and acute hypertension Cardiomyopathy Diabetes Lone No discernible etiology Age less than 60 years Could be applied to patients with no underlying CV disease of any age

15 Sick Sinus Syndrome Valvular heart disease Stress Cardiotoxins/Stimulants Chemotherapeutics Alcohol Stimulant drugs Caffeine Etiology cont.

16 Etiology cont. Thyrotoxicosis and hyperthyroidism Acute inflammation Pericarditis Pneumonia/Pleuritis Viral Illnesses Chronic inflammation Connective Tissue Disorder Chronic Pericardial Effusion

17 Case Study II A 51 year old Asymptomatic Female with no significant chronic medical history presents with a complaint of noticing an irregular heart rate over the past 2-3 weeks. A 48 hour holter shows NSR with 1 one non-sustained episode of the following:

18 Case Study II

19 Which of the following medications is appropriate at this time? A. Amiodarone B. Atenolol C. Warfarin D. Verapamil E. None of the Above

20 Which of the following medications is appropriate at this time? A. Amiodarone B. Atenolol C. Warfarin D. Verapamil E. None of the Above

21 Symptoms Palpitations Fast, racing heart beat Awareness of heart beat Evaluation Chest Discomfort Shortness of Breath Lightheadedness Fatigue/Lack of Energy Exercise Intolerance Abdominal Discomfort Many have no symptoms at All!

22 Evaluation Physical findings Irregular rhythm (may be only physical finding) Some cases a rapid rhythm Varying intensity of first heart sound Occasional pulse deficit compared to auscultated rate CHF presentation Hypoxemia Other findings associated with etiology

23 Evaluation First Best Tool Electrocardiogram 12 lead, holter/telemetry/event/implantable loop Persistence, rate, rhythm PQRS Morphology LVH Pre-Excitation Conduction delays such as BBB, QT interval Other Rhythms J Am Coll Cardiol. 2011;57(11):e101-e198. doi: /j.jacc

24 Evaluation Screening for Etiology Echocardiogram Valve disorder Cardiomyopathy/Cardiomegaly Chamber Dimensions Thrombus Pericardial disease Stress testing Ischemia if positive possible cardiac cath Stress induced AF Laboratory evaluation for anemias, thyroid function, glucose, liver/renal disease, and inflammatory markers if indicated Other later tools EP Study J Am Coll Cardiol. 2011;57(11):e101-e198. doi: /j.jacc

25 Case Study III A 77 year old Female with a History of Non- Ischemic Cardiomyopathy, Hypertension, and COPD presents with Mild, Intermittent New Onset Neurological Changes including near syncopal episodes.

26 Case III

27 Case III

28 Which of the following options would be the most appropriate next clinical option? A. Emergent cardioversion B. Administer IV Esmolol C. Initiate Amiodarone and Heparin D. Consult Cardiology for possible pacemaker placement.

29 Which of the following options would be the most appropriate next clinical option? A. Emergent cardioversion B. Administer IV Esmolol C. Initiate Amiodarone and Heparin D. Consult Cardiology for possible pacemaker placement.

30 Therapeutic Approach Strategic Objectives Rate Control Conversion of Rhythm to Sinus Prevent thromboembolism J Am Coll Cardiol. 2011;57(11):e101-e198. doi: /j.jacc

31 Rate Control This option is selected when patient maintains a tachycardic rate (symptoms or no symptoms) and/or underlying etiology cannot be reversed Also appropriate when patient has been in persistent fibrillation for more than 3 months rate of recurrence >50% at one year and 80% at three years if cardioversion attempted

32 Rate Control Any agent that reduces AV node conduction will slow the ventricular response Options (acute or chronic) Beta Blockers (Esmolol (IV Only), Atenolol/Propranolol, Metoprolol, Bisoprolol,, Nebivolol, Carvedilol) Calcium Channel Blockers (Non-Dihydropyridine Verapamil and Diltazem in IV or PO) Digoxin (less effective as a lone agent) Amiodarone (CCB and Digoxin contraindicated in WPW) J Am Coll Cardiol. 2011;57(11):e101-e198. doi: /j.jacc

33 Conversion to Sinus If patient hemodynamically unstable, immediate conversion required (Electrical Preferred) Stable or Unstable Options Are Electrical Pharmacologic Address and stabilize causational factors Cardioversion success less with significant enlargement of LV, LA or RA, or with significant valve disease

34 Conversion Electrical Bipolar countershock most effective at lower energy Sedation and Anticoagulation required TEE Prior to Cardioversion Rare serious complication Ventricular fibrillation Cardiac standstill Embolization

35 Conversion Usually started on Pre-Treatment Medication Commonly used includes Flecanide, Amiodarone, Propafenone, Sotalol. Less commonly used Ibutilide. 85% of Cardioversions successful initially Reversion to fibrillation most frequent within 24 hours Patient may develop first or second degree burn at pad sites If unsuccessful or if recurs, may repeat with pretreatment with antiarrhythmic

36 Conversion Pharmaceutical Intravenous Ibutilide Dofetilide Amiodarone Oral Dofetilide Flecainide Propafenone

37 Conversion Cautions with medical conversion All agents except amiodarone increase risk of ventricular proarrhythmia in patients with reduced LV function or chamber dilation Flecainide (if no known CAD), dronedarone, and amiodarone may be used safely as outpatient therapy, but all others must be used in hospital with telemetry monitoring All agents may prolong QTc, so screen for other agents that may worsen this (H2 blockers, tricyclics, etc)

38 Maintenance of Sinus Long term success of conversion varies depending on etiology and duration of fibrillation Low risk patients: (one or no risk factors) No antiarrhythmic indicated Higher risk patients: (more than one risk factor or prior episode) Antiarrhythmic indicated Recurrence rate still approaches 50% at one year With advanced AV node disease, antiarrhythmics should not be used without permanent pacemaker

39 Prevention of Thrombosis Clinically most important risk of atrial fibrillation is thrombosis and embolus, especially cerebral Highest risk Rheumatic or other significant valvular disease Dilated LA or LV with cardiomyopathy Prior embolic event J Am Coll Cardiol. 2011;57(11):e101-e198. doi: /j.jacc

40 Estimated 10-year stroke risk in adults 55 years of age according to levels of various risk factors (Framingham Heart Study). Roger V L et al. Circulation 2011;123:e18-e209 Copyright American Heart Association

41 Thromboembolic Risk Assessment

42 CHADS 2 -> CHA 2 DS 2 VASc CHADS2 Risk Score CHA2DS2-VASc Risk Score CHF 1 Hypertension 1 Age > 75 1 Diabetes 1 CHF or LVEF < 40% Hypertension 1 Age > 75 2 Diabetes 1 Stroke/TIA/ Thromboembolism 1 2 Stroke or TIA 2 Vascular Disease 1 From ESC Ahttp:// F Guidelines Age Female 1

43 Thrombus Prevention Multiple randomized trials over the past ten years clearly indicate the benefit of anticoagulation. Risk reduction by 60% Requires warfarin anticoagulation to an INR level of 2.0 to attain best reduction Risk of bleed when carefully monitored is less than 3% per year in patients under 70years of age

44 Thrombus Prevention Anticoagulation not indicated: bleeding disorder history of hemorrhage compliance problems CNS tumor Clopidogrel and Aspirin A Possible Option

45 Thrombosis Prevention If thromboembolic event occurs with INR at target, new target INR of should be established before adding platelet inhibitors

46 Connolly SJ et al. N Engl J Med 2009;361: Connolly SJ et al. N Engl J Med 2010;363: Alternatives to Warfarin Dabigatran

47 Alternatives to Warfarin Rivaroxaban Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med 2011; 365:

48 Interventional Therapy AV Node ablation with permanent pacemaker Indicated for refractory afib with uncontrollable rapid rate response Catheter Ablation Newer techniques enable success at 60-70% Still requires anticoagulation

49 Interventional Therapy Surgical occlusion of atrial appendage at time of valve or bypass surgery Transcatheter occlusion of atrial appendage with mesh device Surgical atrial ablation: Maze procedure Effective at time of valvular surgery

50 Case Study IV An 82 year old Male with a History of Hypertensive Heart Disease Presents to your ER after a Witnessed Syncopal Episode. He is currently stable neurologically and has good BP control. He is experiencing mild shortness of breath but appears comfortable.

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52 Which of the following would be the most appropriate next clinical option? A. Begin treatment for ACS. B. Prepare for emergent cardioversion. C. Place the patient on a holter monitor. D. Send patient home immediately to get his correct insurance cards.and co-pay!

53 Which of the following would be the most appropriate next clinical option? A. Begin treatment for ACS. B. Prepare for emergent cardioversion. C. Place the patient on a holter monitor. D. Send patient home immediately to get his correct insurance cards.and co-pay!

54 Summary Atrial Fibrillation is the most common tachy dysrhythmia seen in the United States. Three Key Objectives for management of Afib include rate control, return to rhythm, thromboembolic protection