1 / 58

Atrial Fibrillation Rate or Rhythm Control

Atrial Fibrillation Rate or Rhythm Control. Saeed Oraii MD Tehran Arrhythmia Clinic April 2007 Shiraz. “Delirium Cordis ”. First described by Sir William Harvey in 17th century: observed chaotic motion of atria in open chest animal

johannes
Download Presentation

Atrial Fibrillation Rate or Rhythm Control

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Atrial FibrillationRate or RhythmControl Saeed Oraii MD Tehran Arrhythmia Clinic April 2007 Shiraz

  2. “Delirium Cordis” • First described by Sir William Harvey in 17th century: observed chaotic motion of atria in open chest animal • Heart rhythm irregularity first described in 1903 by Hering • ECG findings described in 1909 by Sir Thomas Lewis: “irregular or fibrillatory waves and irregular ventricular response” or “absent atrial activity with grossly irregular ventricular response”

  3. Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis • 6% PSVT • 6% PVCs • 18% Unspecified 2% VF • 4% Atrial Flutter • 9% SSS • 34% Atrial Fibrillation • 8% Conduction Disease • 10% VT • 3% SCD Baily D. J Am CollCardiol. 1992;19(3):41A.

  4. Incidence and Prevalence • Prevalence increases with age • 4.8 % in the 70-79 age group • Increases to • 8.8% in the 80-89 age group • During the next 7-8 years, the number of people over the age of 80 is expected to quadruple

  5. Atrial Fibrillation Demographics by Age U.S. populationx 1000 Population with AFx 1000 Population withatrial fibrillation 30,000 20,000 10,000 0 500 400 300 200 100 0 U.S. population <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 >95 Age, yr Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.

  6. Projected AF Prevalence: OLMSTED COUNTY DATA 12% observed increase in AF incidence between 1980 and 2000 Miyasaka et al, Circulation 2005; 114:119

  7. Projections of AF Prevalence in the United States Adults With AF (millions) Adapted from Go. JAMA. 2001;285:2370.

  8. Complications and Prognosis • 5-fold increase in risk of stroke and thromboembolism • Strokes associated with AF are more severe • Death: OR 1.5 –1.9 • AF worsens diagnosis in CHD and HF • Impairment in cognitive function • Reduced exercise tolerance

  9. The 10,000 Foot View … • The prevalence of AF is rapidly increasing • Aging population • True increase in incidence • Lifetime risk of AF at age 40 is 25% • AF is a progressive disorder • Cardiac remodeling due to genetic factors, acquired disease, atrial fibrillation itself • Up to 25% of initially self-terminating AF will become chronic in 5 years, > 50% at 10 years • Associated with substantial risk of adverse outcomes beyond immediate symptoms • Stroke • Congestive heart failure • Death • Associated with substantial increase in health care costs and resource utilization

  10. Therapeutic Approaches to Atrial Fibrillation • Anticoagulation • Rate Control (ventricular response) • Pharmacologic • Catheter modification/ablation of AV node • Rhythm Control • Antiarrhythmic suppression • Curative procedures • Catheter ablation • Surgery (maze)

  11. Thromboembolic prophylaxis • Thromboembolic events do not just occur in permanent AF • Consider treatment for all patients with AF • Clustering of events at the time of onset • 62% RR reduction with adjusted dose Warfarin • 22% RR reduction with Aspirin • 0.9% absolute risk increase of major haemorrhage with Warfarin

  12. Risk Assessment Tools • Do not apply to valvular heart disease • Risk of thromboembolism depends on other risk factors in patients with AF • Various risk assessment tools available • There are differences between CHAD2 and the tool favoured in the NICE guidelines

  13. CHAD2 Score

  14. Therapeutic Approaches to Atrial Fibrillation • Anticoagulation • Rate Control • Pharmacologic • Catheter modification/ablation of AV node • Rhythm Control • Antiarrhythmic suppression • Curative procedures • Catheter ablation • Surgery (maze)

  15. AF: Pharmacologic Rate Control • Digitalis • Beta Blockers • Calcium Channel Blockers (verapamil, diltiazem) • Amiodarone (in special settings)

  16. Atrial Fibrillation: Rate Control • Essential in all patients • Persistent tachycardia rates can induce cardiomyopathy and heart failure • Occasional follow-up holter monitor to ascertain rate control • Target: 60-80 bpm rest 90-115 bpm with exercise

  17. Adequate Rate Control • AFFIRM • Average HR of ≤80 beats/min at rest and either a maximum of ≤110 bpm during a 6-minute walk or an average of <100 bpmon 24-hour Holter monitoring, with the rate not exceeding 110% of maximum predicted age-adjusted exercise rate. • RACE • Resting heart rate on a 12-lead ECG of ≤100 beats/min • HOT CAFÉ • A heart rate of 70–90 beats/min on a resting 12-lead ECG and ≤140 beats/min during moderate exercise

  18. Digoxin: some words of caution • Oldest and most commonly prescribed drug for control of ventricular rate • Predominant acute effect is mediated by the autonomic nervous system • An important slowing effect of the AV node is mediated by enhanced vagal tone • Not effective during periods of increased sympathetic tone • Not effective in paroxysmal atrial fibrillation

  19. AVN Ablation and PPM • Paroxysmal AF – DDDR pacing with mode switch • Permanent AF – VVIR pacemaker • Biventricular devices may be better in preserving LV function

  20. AVN Ablation and PPM • Pros: • Controls and regularizes ventricular rate • Effective at improving symptoms, QOL and ? LV function • Cons: • Permanent • Detrimental effects of RV pacing, especially if reduced LV function already • Still have thromboembolic risk • Continue to have loss of atrial contractile function

  21. Ablate and pace • Suitable for • AF with symptomatic rapid ventricular rate unresponsive to drug Rx, or when drug Rx not tolerated • Curative AF ablation not suitable or not possible • Patients with a bradycardia indication for pacing • More suited to elderly (less requirement for generator changes and lead revision)

  22. Therapeutic Approaches to Atrial Fibrillation • Anticoagulation • Rate Control (ventricular response) • Pharmacologic • Catheter modification/ablation of AV node • Rhythm Control • Antiarrhythmic suppression • Curative procedures • Catheter ablation • Surgery (maze)

  23. AF: Rhythm Control Options

  24. Disadvantages High recurrence rate High long-term cost Non-curative Adverse effects Potential proarrhythmia Advantages High efficacy for somepatients, at leastinitially (< 50% of all patients) Low initial cost Noninvasive Antiarrhythmic Therapy for Atrial Fibrillation

  25. Proarrhythmia Drug-induced Torsade

  26. Rhythmvs Rate control Trials • PIAF • Lancet 2000 • AFFIRM • NEJM 2002 • RACE • NEJM 2002 • STAF • JACC 2003 • Hot CAFÉ • Chest 2004

  27. Rate vs. Rhythm control • None of the RCTs found rate control inferior in terms of mortality or quality of life. • One study showed rate control reduced the mortality in patients without Heart Failure, in over 65s and in patients with CHD. • Reduced rates of hospitalization and adverse events with rate control • No difference in the rate of thromboembolic or hemorrhagic events • Rate control is more cost effective.

  28. AFFIRM: Atrial Fibrillation Follow-up Investigationof Rhythm Management Design Multicenter, randomized, open, parallel group Patients 4060 patients who had atrial fibrillation that was likely to be recurrent, with other risk factors for stroke or death. Patients with contraindications for anticoagulant therapy were excluded Follow up and primary endpoint Primary endpoint: all-cause mortality. Mean 3.5 years follow up. Treatment • Rate control:>1 rate-controlling drugs, plus anticoagulant, or • Rhythm control:>1 antiarrhythmics, plus cardioversion as necessary; anticoagulant encouraged but could be discontinued Nonpharmacological therapies and changes in pharmacological therapy, including crossover between groups, were permitted. The AFFIRM Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–33.

  29. Rate control Rhythm control (n=2027) (n=2033) 70 70 41 38 25 28 5 5 52 50 5 5 1 1 13 12 23 23 AFFIRM Baseline characteristics Overall (n=4060) a 70 Age (years) Female (%) 39 Predominant cardiac diagnosis (%) Coronary artery disease 26 Cardiomyopathy 5 51 Hypertension 5 Valvular disease Other 1 No apparent heart disease 12 History of congestive 23 heart failure (%) a Mean AFFIRM Investigators. N Engl J Med 2002; 347 :1825 – 33.

  30. b These patients immediately crossed over to the rhythm control group, a protocol violation AFFIRM a Drugs used in rate and rhythm control groups Rate control Rhythm control Used drug for Used drug Used drug for Used drug initial therapy at any time initial therapy at any time No. (%) No. (%) No. (%) No. (%) Rate control: data available 1957 2027 1266 2033 Digoxin 949 (48.5) 1432 (70.6) 417 (32.9) 1106 (54.4) Beta-blocker 915 (46.8) 1380 (68.1) 276 (21.8) 1008 (49.6) Diltiazem 583 (29.8) 935 (46.1) 198 (15.6) 610 (30.0) Verapamil 187 (9.6) 340 (16.8) 56 (4.4) 204 (10.0) Rhythm control: data available 1265 2027 1960 2033 b Amiodarone 2 (0.2) 207 (10.2) 735 (37.2) 1277 (62.8) b Sotalol 1 (0.1) 84 (4.1) 612 (31.2) 841 (41.4) a A few patients in the rate and a significant number in the rhythm control groups received other antiarrhythmics AFFIRM Investigators. N Engl J Med 2002; 347 :1825 – 33.

  31. AFFIRM Goals of AFFIRM • Resting HR <80 • 24 hr Holter average <100 bpm. No HR above 110% of age predicted maximum • HR <110 on a six min walk Anticoagulate: -If over 48hrs of AF, must anticoag before cardioversion. -Warfarin (6-12wks), heparin, LMWH -Aspirin -If Lone AF aspirin or nothing

  32. AFFIRM- RESULTS - • No significant difference between rate control and rhythm control groups in: • all-cause mortality (25.9 vs. 26.7%, P=0.08) • composite secondary endpoint (death, disabling stroke or anoxic encephalopathy, major bleeding, and cardiac arrest) • total number of central nervous system events (stroke or hemorrhage) • Nonsignificant trends were towards reduction of all-cause mortality and CNS events with rate control, compared with rhythm control • Significantly reduced hospitalization in rate control group compared with rhythm control • Fewer patients initially assigned to rate control crossed over to rhythm control than crossed from rhythm to rate control (15 vs. 38% at 5 years; P<0.001)

  33. AFFIRM- RESULTS - All-cause mortality Cumulative 30 mortality (%) 25 20 15 P=0.08 10 5 Rhythm control Rate control 0 0 1 2 3 4 5 Years after randomization AFFIRM Investigators. N Engl J Med 2002; 347 :1825 – 33.

  34. AFFIRM- RESULTS - Primary and selected secondary endpoints Rhythm control Overall Rate control (n=2033) (n=4060) (n=2027) P No. (%) No. (%) No. (%) Primary endpoint: all-cause mortality 666 (26.3) 310 (25.9) 356 (26.7) 0.08 Secondary endpoint: 861 (32.3) 416 (32.7) 445 (32.0) 0.33 death, disabling stroke, disabling encephalopathy, major bleeding, and cardiac arrest CNS eventa 211 (8.2) 105 (7.4) 106 (8.9) 0.93 Hospitalization 2594 (76.6) 1220 (73.0) 1374 (80.1) <0.001 a Ischemic stroke, or primary intracerebral or subdural/subarachonoid hemorrhage AFFIRM Investigators. N Engl J Med 2002; 347 :1825 – 33.

  35. AFFIRM- SUMMARY- In patients who had atrial fibrillation and were at high risk for stroke or death, comparison of rate and rhythm control showed: • No significant difference in all-cause mortality, composite secondary endpoint (death, disabling stroke, disabling anoxic encephalopathy, major bleeding, cardiac arrest) or ischemic stroke • A nonsignificant trend to reduction of all-cause mortality and stroke with rate control • Reduced hospitalization with rate control Crossover to the other control method was lower in the rate control group

  36. RACE TrialRate Control vs. Electrical Cardioversion • 522 patients with persistent atrial fibrillation or atrial flutter (24 hours-1 year) • 2 cardioversions within 1 year • Rate control to HR < 100 bpm and no symptoms • Rhythm control: Sotalol followed by Flecainide or Propafenone followed by Amiodarone • Primary endpoint: cardiovascular death, admission or CHF, Thromboembolic events, severe bleeding, pacemaker implantation or severe anti-arrhythmic side effects

  37. RACE Study 522 Patients 256 patients – rate control 266 patients – cardioversion OutcomeRateRhythm Death/Stroke 17.2% 22.6% Mortality 7% 6.7% CHF 3.5% 3.4% Hypertension Subgroup: Combined Endpoints: Mortality/thromboembolism/severe complication RateRhythm 19% 31%

  38. Rate vs. Pharmacologic Rhythm control Favor of rate control Favor of rhythm control • Persistent AF • History of AF more than 1 year • Less symptomatic • > than 65 years of age • History of HTN • Previous AAD failure • LA > 60 mm • No history of CHF • Patient preference • Paroxysmal AF • First episode of AF • More Symptomatic • < than 65 years of age • No history HTN • No Previous AAD failure • LA < 60 mm • History CHF • Patient preference

  39. Who is under-represented in AFFIRM? • Young patients • Paroxysmal atrial fibrillation • CHF • Reduced systolic function • Isolated diastolic dysfunction • Disabling symptoms of AF What therapies are under-represented ? Other (newer?) drugs Non-pharmacologic therapies

  40. What AFFIRM Does Not Tell Us? • Optimal management for patients with moderate or severe disabling symptoms related to atrial fibrillation • Outcome if better tools to maintain sinus rhythm were available • Long-term implications of rate vs. rhythm control (mean duration of follow-up only 3.5 years)

  41. Nonpharmacological Approaches to Atrial Fibrillation Pacemaker therapy 2. Ablation 3. Surgery

  42. Pulmonary Vein Triggers

  43. Segmental Ablation

  44. Segmental Ablation

  45. Circumferential Ablation

  46. Circumferential Ablation

  47. Circumferential Ablation

  48. Randomized Trials of Ablation for PAF • STABILE: EHJ 2006 27:216-221; prior AAD failure; 1 episode/mo 6 mo duration; included 32% persistent AF; AAD given to ablation group; PVI+MI+CTI; blanking 1 mo; HM + 3 mo daily event montioring; endpoint 30 sec AF • WANZI: JAMA 2005: 293:2634-2640); No prior AAD; 1 episode/mo 3 mo duration; PVAI; blanking 2 mo; HM + 1,3 mo event monitoring; endpoint 15 sec AF. Pilot study for RAAFT (400 pt trial) • JAIS: HRS Scientific Sessions 2006; Prior AAD failure, 2 episodes/mo 6 mo duration; PVI+CTI+lines; blanking 3 mo; HM + symptom diaries; endpoint 3 min AF or palpitations • PAPPONE: JACC 2006 in press, doi 10:1016. Limited prior AAD; 2 episodes /mo 6 mo duration;CPVI+CTI+lines; blanking 6 wks, daily event monitoring; endpoint 30 sec AF Major complications in 1-4% of ablation groups

  49. Can Ablation Improve Survival? Pappone et al JACC 2003; 42:186-197

  50. Catheter ABlation Versus ANtiarhythmic Drug Therapy for Atrial Fibrillation (CABANA) • Randomized trial comparing ablation to best drug therapy (rate or rhythm control) • Primary endpoint: mortality (powered for 30% mortality reduction assuming 12% 3 yr mortality in drug group) • Secondary endpoints: • Composite (death, disabling stroke, serious bleeding, cardiac arrest) • Freedom from AF recurrence (irrespective of symptoms) • Health care costs and resource utilization • Quality of life • Planned 3000 pts, 120 enrolling centers • Pilot phase approved starting late 2006, full study pending approval

More Related