Atrial fibrillation evidence based care 2011
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Atrial Fibrillation Evidence Based Care 2011. 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. 7.0. 6.0. 5.61. 5.42.

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Atrial Fibrillation Evidence Based Care 2011

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Atrial fibrillation evidence based care 2011

Atrial Fibrillation Evidence Based Care2011

Allan Anderson, MD, FACC, FAHA

Division of Cardiology


Projection for prevalence of atrial fibrillation 5 6 million by 2050

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

7.0

6.0

5.61

5.42

5.0

5.16

4.78

4.34

4.0

Adults with atrial fibrillation

in millions

3.80

3.33

3.0

2.94

2.66

2.44

2.26

2.0

2.08

1.0

Upper and lower curves represent the upper and lower scenarios based on sensitivity analyses.

0

1990 1995 2000 200520102015 2020 2025 20302035 2040 2045 2050

Years

Go AS et al. JAMA. 2001;285:2370-2375.


Atrial fibrillation is associated with increased mortality

Atrial Fibrillation Is Associated With Increased Mortality

With atrial fibrillation

Without atrial fibrillation

71.3

65.1*

62.4

54.5

51.0*

47.5

47.4*

38.6

36.1*

Cumulative mortality over 3 years (%)

34.0

30.2*

25.4*

Women

Men

Women

Men

Women

Men

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

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.


Atrial fibrillation evidence based care 2011

Increasing Hospitalizations in the United States When Atrial Fibrillation Is Principal Diagnosis(National Hospital Discharge Survey)

140

120

100

80

60

40

20

0

Prevalence per 10,000 persons

1985

1987

1991

1993

1995

1997

1999

1989

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

Atrial Fibrillation Adversely Affects Quality of Life (QoL)

Lower scores = poorer QoL

SF-36 score

Dorian P et al. J Am Coll Cardiol. 2000;36:1303-1309.


Famous fibrillators

Famous Fibrillators


Famous fibrillators1

Famous Fibrillators


Famous fibrillators2

Famous Fibrillators


Famous fibrillators3

Famous Fibrillators


Famous fibrillators4

Famous Fibrillators


Famous fibrillators5

Famous Fibrillators


Famous fibrillators6

Famous Fibrillators


Atrial fibrillation 2011

Atrial Fibrillation2011

  • Patterns of AF

  • Evaluation of Patient

  • Evidence Base

    • Rate Management

    • Rhythm Management

    • Prevention of thromboembolism

  • New stuff


Patterns of atrial fibrillation

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

Atrial FibrillationEvaluation of Patients

History and physical examination

Presence and nature of associated symptoms

Clinical type (1st episode, paroxysmal, persistent, permanent)

Onset/date of discovery of 1st 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 patients1

Atrial FibrillationEvaluation 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 patients2

Atrial FibrillationEvaluation 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 patients3

Atrial FibrillationEvaluation 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)


The guidelines

The Guidelines

Class I: Conditions for which there is evidence and/or general agreement that a given procedure/therapy is beneficial, useful, and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy.

IIA: Weight of evidence/opinion is in favor of usefulness/efficacy.

IIB: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful or effective and in some cases may be harmful.


Level of evidence

Level of Evidence

A: Data derived from multiple randomized clinical trials or meta-analyses.

B: Data derived from a single randomized trial, or nonrandomized studies.

C: Only consensus opinion of experts, case studies, or standard-of-care.


Expert opinion

Expert Opinion

One who knows enough jargon to be both confusing and dangerous.

Ambrose Bierce

1842-1913


Consensus

Consensus

  • General agreement within a group, especially after protracted, lengthy, bitter debate and loss of life.

  • Opinion obtained by straw polling when the opposition is not present. See team building.

  • The current thinking of the team supervisor.


Rate or rhythm control

Rate or Rhythm Control?


Comparison of trials rate vs rhythm control

Comparison of TrialsRate vs. Rhythm Control

Clinical Events


Atrial fibrillation evidence based care 2011

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, life-threatening 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.


Atrial fibrillation evidence based care 2011

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.


Atrial fibrillation the thou shalt s

Atrial FibrillationThe “Thou Shalt’s”

Pharmacologic Rate Control (Class I)

Measurement of the heart rate at rest and control of the rate using pharmacological agents (either a beta blocker or non-dihydropyridine calcium channel antagonist, in most cases) are recommended for patients with persistent or permanent AF. (Level of Evidence: B)


Atrial fibrillation the thou shalt s1

Atrial FibrillationThe “Thou Shalt’s”

Pharmacologic Rate Control (Class I)

In the absence of pre-excitation, intravenous administration of beta blockers (esmolol, metoprolol, or propranolol) or non-dihydropyridine calcium channel antagonists (verapamil, diltiazem) is recommended to slow the ventricular response to AF in the acute setting, exercising caution in patients with hypotension or HF. (Level of Evidence: B)


Atrial fibrillation the thou shalt s2

Atrial FibrillationThe “Thou Shalt’s”

Pharmacologic Rate Control (Class I)

Intravenous administration of digoxin or amiodarone is recommended to control the heart rate in patients with AF and HF who do not have an accessory pathway. (Level of Evidence: B)


Atrial fibrillation the thou shalt s3

Atrial FibrillationThe “Thou Shalt’s”

Pharmacologic Rate Control (Class I)

In patients who experience symptoms related to AF during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. (Level of Evidence: C)


Atrial fibrillation the thou shalt s4

Atrial FibrillationThe “Thou Shalt’s”

Pharmacologic Rate Control (Class I)

Digoxin is effective following oral administration to control the heart rate at rest in patients with AF and is indicated for patients with HF, LV dysfunction, or for sedentary individuals. (Level of Evidence: C)


Atrial fibrillation the thou shalt not s

Atrial FibrillationThe “Thou Shalt Not’s”

Pharmacologic Rate Control (Class III)

Digitalis should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal AF. (Level of Evidence: B)

Catheter ablation of the AV node should not be attempted without a prior trial of medication to control the ventricular rate in patients with AF. (Level of Evidence: C)


Atrial fibrillation the thou shalt not s1

Atrial FibrillationThe “Thou Shalt Not’s”

Pharmacologic Rate Control (Class III)

In patients with decompensatedHF and AF, intravenous administration of a non-dihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended. (Level of Evidence: C)

Intravenous administration of digitalis glycosides or non-dihydropyridine calcium channel antagonists to patients with AF and a pre-excitation syndrome may paradoxically accelerate the ventricular response and is not recommended. (Level of Evidence: C)


Atrial fibrillation evidence based care 2011

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


Atrial fibrillation the thou shalt s5

Atrial FibrillationThe “Thou Shalt’s”

Maintenance of sinus rhythm (Class I)

Before initiating anti-arrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C)


Atrial fibrillation the thou shalt not s2

Atrial FibrillationThe “Thou Shalt Not’s”

Maintenance of sinus rhythm (Class III)

Antiarrhythmic therapy with a particular drug is not recommended for maintenance of sinus rhythm in patients with AF who have well-defined risk factors for proarrhythmia with that agent. (Level of Evidence: A)

Pharmacological therapy is not recommended for maintenance of sinus rhythm in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning electronic cardiac pacemaker. (Level of Evidence: C)


Prevention of thromboembolism

Prevention of Thromboembolism


Effects on all stroke ischemic and hemorrhagic of therapies for patients with atrial fibrillation

Effects on all stroke (ischemic and hemorrhagic) of therapies for patients with atrial fibrillation


Stroke risk prediction in af chads 2 criteria

Stroke Risk Prediction in AFCHADS2 Criteria

Walraven WC et al. JAMA 2001;285:2864–70 (426).


Stroke risk prediction in af chads 2 criteria1

Stroke Risk Prediction in AFCHADS2 Criteria

Walraven WC et al. JAMA 2001;285:2864–70 (426).


Atrial fibrillation the thou shalt s6

Atrial FibrillationThe “Thou Shalt’s”

Prevention of thromboembolism (Class I)

Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications. (Level of Evidence: A)

The selection of the antithrombotic agent should be based upon the absolute risks of stroke and bleeding and the relative risk and benefit for a given patient. (Level of Evidence: A)


Atrial fibrillation the thou shalt s7

Atrial FibrillationThe “Thou Shalt’s”

Prevention of thromboembolism (Class I)

For patients without mechanical heart valves at high risk of stroke, chronic oral anticoagulant therapy with a vitamin K antagonist is recommended in a dose adjusted to achieve the target intensity INR of 2.0 to 3.0, unless contraindicated. Factors associated with highest risk for stroke in patients with AF are prior thromboembolism (stroke, TIA, or systemic embolism) and rheumatic mitral stenosis. (Level of Evidence: A)

Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor. Such factors include age 75 y or greater, hypertension, HF, impaired LV systolic function (ejection fraction 35% or less or fractional shortening less than 25%), and diabetes mellitus. (Level of Evidence: A)


Atrial fibrillation the thou shalt s8

Atrial FibrillationThe “Thou Shalt’s”

Prevention of thromboembolism (Class I)

INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Level of Evidence: A)

Aspirin, 81–325 mg daily, is recommended as an alternative to vitamin K antagonists in low-risk patients or in those with contraindications to oral anticoagulation. (Level of Evidence: A)

For patients with AF who have mechanical heart valves, the target intensity of anticoagulation should be based on the type of prosthesis, maintaining an INR of at least 2.5. (Level of Evidence: B)

Antithrombotic therapy is recommended for patients with atrial flutter as for those with AF. (Level of Evidence: C)


Atrial fibrillation the thou shalt not s3

Atrial FibrillationThe “Thou Shalt Not’s”

Prevention of thromboembolism (Class III)

Long-term anticoagulation with a vitamin K antagonist is not recommended for primary prevention of stroke in patients below the age of 60 y without heart disease (lone AF) or any risk factors for thromboembolism. (Level of Evidence: C)


Dabigatran pradaxa

Dabigatran (Pradaxa)

Direct thrombin inhibitor

Dose:

CrCl > 30: 150 mg twice daily

CrCl < 30: 75 mg twice daily

See prescribing information on transitions between warfarin or parenteral anticoagulants


Dabigatran pradaxa1

Dabigatran (Pradaxa)

1.5 % risk of life threatening bleeding vs. 1.8% for warfarin (RE-LY)

Avoid with Rifampin (P-gp inducer)

Pregnancy Class C

Major side effects: bleeding; gastrointestinal


Dabigatran versus warfarin in patients with atrial fibrillation re ly

Dabigatran versus Warfarin in Patients with Atrial FibrillationRE-LY

Non-inferiority trial

18,113 patients randomized

110 or 150 mg dabigatran – blinded

Adjusted dose warfarin – unblinded

2.0 year median follow-up

Primary outcome: stroke or systemic embolization

Connolly SJ, et al. N Engl J Med 2009; 361:1139-1151.


Atrial fibrillation evidence based care 2011

RE-LY

Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism

According to Treatment Group.

Connolly SJ et al. N Engl J Med 2009;361:1139-1151.


A few words about af ablation

A Few Words About AF Ablation

Increasingly effective procedure, depending on type of AF

Paroxysmal > Persistent > Permanent

Failure of drug therapy or importance of maintaining SR for hemodynamic purposes

Not without risk – requires experience


Thank you

Thank You!

Questions??


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