Atrial Fibrillation 2014 How to Treat How to Anticoagulate Allan Anderson, MD, FACC, FAHA Division of Cardiology
Projection for Prevalence of Atrial Fibrillation: 5.6 Million by 2050 Projected number of adults with atrial fibrillation in the United States between 1995 and 2050 Adults with atrial fibrillation in millions 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0 5.61 5.42 5.16 4.78 4.34 3.80 3.33 2.94 2.66 2.44 2.08 2.26 Upper and lower curves represent the upper and lower scenarios based on sensitivity analyses. 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Years Go AS et al. JAMA. 2001;285:2370-2375.
Atrial Fibrillation Is Associated With Increased Mortality Cumulative mortality over 3 years (%) 80 With atrial fibrillation Without atrial fibrillation 70 60 54.5 50 47.4* 47.5 38.6 40 34.0 36.1* 30.2* 30 25.4* 20 10 0 71.3 65.1* 62.4 51.0* 65-74 years of age 75-84 years of age 85-89 years of age * Significantly different from patients with atrial fibrillation (P<.05). Wolf PA et al. Arch Intern Med. 1998;158:229-234.
Atrial Fibrillation: Major Cause of Stroke in the United States 15% of all strokes attributable to atrial fibrillation 75,000 strokes per year attributable to atrial fibrillation 3- to 5-fold increase in risk of stroke in patients with atrial fibrillation Stroke risk persists even in asymptomatic atrial fibrillation Go AS et al. JAMA. 2001;285:2370-2375; Go AS. Am J Geriatr Cardiol. 2005;14:56-61; Wolf PA et al. Stroke. 1991;22:983-988; Benjamin EJ et al. Circulation. 1998;98:946-952; Page RL et al. Circulation. 2003;107:1141-1145.
Increasing Hospitalizations in the United States When Atrial Fibrillation Is Principal Diagnosis (National Hospital Discharge Survey) Prevalence per 10,000 persons 140 120 100 80 60 40 20 0 1985 1987 1989 1991 1993 1995 1997 1999 Year Age (years) 85+ 75 to 84 65 to 74 55 to 64 35 to 54 Wattigney WA et al. Circulation. 2003;108:711-716.
Atrial Fibrillation Adversely Affects Quality of Life (QoL) 120 Lower scores = poorer QoL 100 SF-36 score 80 60 40 20 54 59 78 68 70 88 71 85 92 68 76 81 Atrial fibrillation Post myocardial infarction Controls 0 General health Physical function Social function Mental health Dorian P et al. J Am Coll Cardiol. 2000;36:1303-1309.
Atrial Fibrillation 2014 Patterns of AF Evaluation of Patient Evidence Base Rate Management Rhythm Management Prevention of thromboembolism New stuff
Patterns of Atrial Fibrillation First Detected Paroxysmal (Self terminating) Persistent (Non self terminating) Permanent Fuster, V. et al. J Am Coll Cardiol 2011;57:e101-e198
Atrial Fibrillation Evaluation of Patients History and physical examination Presence and nature of associated symptoms Clinical type (1 st episode, paroxysmal, persistent, permanent) Onset/date of discovery of 1 st episode Frequency, duration, precipitating factors, mode of termination Response to therapies Establish underlying heart disease or other treatable conditions (e.g., hyperthyroidism, alcohol)
Atrial Fibrillation Evaluation of Patients ECG Verify rhythm LVH? Pre-excitation (WPW)? Bundle branch block? Prior MI? Measure and follow intervals (R-R, QRS, QT) in conjunction with drug therapy
Atrial Fibrillation Evaluation of Patients Transthoracic echocardiogram Valvular disease Chamber sizes/ventricular function Peak RV systolic pressure (pulmonary hypertension) LVH Pericardial disease Atrial clot (usually not helpful, requires TEE)
Atrial Fibrillation Evaluation of Patients Other studies 6 minute walk test: evaluate adequacy of rate control Stress test Adequacy of rate control Reproduce exercise-induced AF Presence of ischemia (regarding use of IC drugs) Holter monitor Verify/establish diagnosis Adequacy of rate and/or rhythm control Transesophageal echocardiogram (TEE) LA clot Guide to cardioversion (expedited)
Rate or Rhythm Control?
Comparison of Trials Rate vs. Rhythm Control Clinical Events Stroke/Embolism Death Trial Patients (n) AF Duration Patients in SR * Rate Rhythm Rate Rhythm AFFIRM (2002) RACE (2002) PIAF (2000) STAF (2003) HOT CAFÉ (2004) 4060 NR 35% vs. 63% (at 5 y) 522 1 to 399 d 10% vs. 39% (at 2.3 y) 252 7 to 360 d 10% vs. 56% (at 1 y) 200 6 3 mo 11% vs. 26% (at 2 y) 205 7 to 730 d NR vs. 64% 88/2027 93/2033 310/2027 356/2033 7/256 16/266 18/256 18/266 0/125 2/127 2/125 2/127 2/100 5/100 8/100 4/100 1/101 3/104 1/101 3/104
Rate Control Efficacy in Permanent Atrial Fibrillation: a Comparison between Lenient versus Strict Rate Control II RACE II 614 patients with permanent AF (age </= 80) Lenient rate control (HR<110 at rest) OR Strict rate control HR < 80 at rest, AND HR < 110 during moderate exercise Composite outcome: CV death, hospitalization for HF, systemic embolism, bleeding, lifethreatening arrhythmia Follow-up: At least 2 years; maximum 3 years Van Gelder IC, Groenveld HF, Crijns HJ, et al. N Engl J Med 2010;362:1363-1373.
Rate Control Efficacy in Permanent Atrial Fibrillation: a Comparison between Lenient versus Strict Rate Control II RACE II 3 year cumulative incidence of primary outcome 12.9% - lenient 14.9% - strict Target HR goal(s) 304 (97.7%) lenient 204 (67%) strict Total Visits 75 lenient 684 - strict P < 0.001 P < 0.001 P < 0.001 Van Gelder IC, Groenveld HF, Crijns HJ, et al. N Engl J Med 2010;362:1363-1373.
Therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation Wann, L. S. et al. J Am Coll Cardiol 2011;57:223-242
Prevention of Thromboembolism
Effects on all stroke (ischemic and hemorrhagic) of therapies for patients with atrial fibrillation
Stroke Risk Prediction in AF CHADS 2 Criteria CRITERIA SCORE Prior stroke or TIA 2 Age > 75 years 1 Hypertension 1 Diabetes Mellitus 1 Heart Failure 1 Walraven WC et al. JAMA 2001;285:2864 70 (426).
Stroke Risk Prediction in AF CHADS-VASC Criteria CRITERIA SCORE Heart Failure 1 Age >/= 75 2 Age 65-47 1 Stroke/TIA/Thromboembolism 2 Diabetes Mellitus 1 Vascular Disease 1 Female Gender 1