Canadian Cardiovascular Society AF Guidelines 2012 Update

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2. Canadian Cardiovascular Society Guidelines 2012 UPDATE Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate / Rhythm Control

3. CCS Atrial Fibrillation Guidelines 2012 Update Primary Panel • Allan Skanes (co chair) • Jeff Healey (co chair) • John Cairns • Stuart Connolly • Jafna Cox • Paul Dorian • Anne Gillis • Laurent Macle • Sean McMurtry • Gordon Gubitz • Brent Mitchell • Stanley Nattel • Pierre Pagé • Ratika Parkash • P. Timothy Pollak • Michael Stephenson • Ian Stiell • Mario Talajic • Teresa Tsang • Atul Verma

4. CCS AF Guidelines 2010 Primary Panel • Anne Gillis (co chair) • Allan Skanes (co chair) • John Cairns • Stuart Connolly • Jafna Cox • Paul Dorian • Jeff Healey • Laurent Macle • Sean McMurtry • Brent Mitchell • Stanley Nattel • Pierre Pagé • Ratika Parkash • P. Timothy Pollak • Michael Stephenson • Ian Stiell • Mario Talajic • Teresa Tsang • Atul Verma

5. CCS AF Guidelines 2010 ∕ 2012 Update Secondary Panel • Malcolm Arnold • David Bewick • Vidal Essebag • Milan Gupta • Brett Heilbron • Charles Kerr • Bob Kiaii • Jan Surkes • George Wyse

6. Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Implementing GRADE and Achieving Consensus Anne M Gillis MD Allan C Skanes MD With special acknowledgement of Jan Brozek MD, PhD

7. A New Approach to Guideline Development & Evaluation GRADE Grading of Recommendations, Assessment, Development and Evaluation

8. GRADE Approach Clear separation of 2 issues: • Four Categories of Quality of Evidence: • High, Moderate, Low or Very Low 2. Strength of Recommendations: 2 Grades • Strong or Conditional (weak) • Quality of evidence only one factor

9. GRADE: Rating Quality of Evidence Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

10. Factors Determining the Strength of the Recommendation Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926

11. Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Investigation Jeff S Healey MD Ratika Parkash MD P Timothy Pollak MD Teresa SM Tsang MD Paul Dorian MD

12. Establish Pattern of Atrial Fibrillation Newly Diagnosed AF Paroxysmal Persistent Permanent Modified with permission from Fuster et al Circulation 2006;114:e257-354

17. RecommendationsEtiology and Investigations

18. Practical Tips • Aggressive treatment of hypertension may prevent or reduce recurrences • Choice of antihypertensive therapy should favor rate controlling drugs e.g. β-blockers and Ca2+ channel blockers vs inhibitors of renin angiotensin system. • Identify and treat obstructive sleep apnea

19. Establish AF SeverityUse to Guide Therapeutic Approach Dorian et al Can J Cardiol 2006;22:383-386

20. Recommendations Quality of Life Values and Preferences: These recommendations recognize that improvement in QOL is a high priority for therapeutic decision making.

22. Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2012: AF/AFL Rhythm Management Anne M Gillis MD Atul Verma MD Mario Talajic MD Stanley Nattel MD Paul Dorian MD

23. Overview of AF Management Detection and Treatment of Precipitating Causes AF Detected Management of Arrhythmia Assessment of Thromboembolic Risk (CHADS2) ASA OAC Rate Control Rhythm Control No antithrombotic therapy may be appropriate in selected young patients with no stroke risk factors

24. Goals of AF Arrhythmia Management • Identify and treat underlying structural heart disease and other predisposing conditions • Relieve symptoms • Improve functional capacity/quality of life • Reduce morbidity/mortality associated with AF/AFL • Prevent tachycardia-induced cardiomyopathy • Reduce/prevent emergency room visits or hospitalizations secondary to AF/AFL • Prevent stroke or systemic thromboembolism

25. Recommendations – Rx Goals Values and Preferences These recommendations place a high value on the decision of individual patients to balance relief of symptoms and improvement in QOL and other clinical outcomes with the potential greater adverse effects of Class I/III antiarrhythmic drugs compared to rate control therapy.

26. Referral for Specialty Care • Most patients with AF/AFL should be considered for referral to a cardiologist or an internist with an interest in cardiovascular disease for an expert opinion on management. • Patients ≤ 35 yr old with symptomatic AF should be referred to an arrhythmia specialist to rule out other forms of SVT that may trigger AF and that would be best treated by radiofrequency ablation. • Patients who remain highly symptomatic despite multiple trials of antiarrhythmic drug therapy, or who remain unresponsive to, or intolerant of rate controlling therapies should be referred to an arrhythmia specialist for an expert opinion on management alternatives.

27. Rate or Rhythm Control? • How do you decide if you are going to pursue rate or rhythm control for a patient with AF? • No right or wrong answer • Often, the two are simultaneous: • Rhythm control requires good rate control when patient goes back into AF • Need to continuously re-evaluate the strategy as the AF progresses • What may have been a good initial strategy may no longer be warranted

28. Factors Influencing Decision of Rate vs Rhythm Control

29. What is Optimal Target Heart Rate? • RACE II suggested that strict rate control (< 80 bpm at rest, < 110 bpm with activity) was no different compared to lenient strategy (< 110 bpm at rest) • However, actual HR in both groups were 75 and 86 bpm respectively • Thus, the trial was not that lenient • Few patients had HR > 100 bpm

30. Ventricular Rate Control Values and Preferences These recommendations place a high value on the randomized clinical trials and other clinical studies demonstrating that ventricular rate control of AF is an effective treatment approach for many patients with AF.

32. Ventricular Rate Control

33. Ventricular Rate Control Values and Preferences These recommendations recognize that the mechanism(s) for the differences between the results of the ATHENA and the PALLAS trials have not yet been determined. These recommendations are based on the known differences between the 2 patient populations and are also informed by the results of the ANDROMEDA trial.

35. Ventricular Rate Control Previous MI or LV Systolic Dysfunction Values and Preferences This recommendation places a high value on the results of multiple randomized clinical trials reporting the benefit of beta-blockers to improve survival and decrease the risk of recurrent myocardial infarction and prevent new-onset heart failure following myocardial infarction as well as the adverse effects of calcium channel blockers in the setting of heart failure.

36. Ventricular Rate Control AV Junction Ablation Values and Preferences This recommendation places a high value on the results of many small randomized trials and one systematic review reporting significant improvements in quality of life and functional capacity as well as a decrease in hospitalizations for AF following AV junction ablation in highly symptomatic patients.

42. Pill in the Pocket For Rhythm Control • Single dose flecainide (200-300 mg) or propafenone (450-600 mg) as an oral dose • Often prescribed with a short-acting beta-blocker at the same time (metoprolol 50-100 mg) Values and preferences This recommendation places a high value on the results of clinical studies demonstrating the efficacy and safety of intermittent antiarrhythmic drug therapy in selected patients.

45. Rhythm Control Does Not Replace Anticoagulation • No evidence that AF reduction via antiarrhythmic therapy reduces the risk of stroke/thromboembolism • Patients must continue on appropriate anticoagulation according to their individual embolic risk (CHADS2 score)

46. Cardioversion for Rhythm Control Values and preferences These recommendations place a high value on the decision of individual patients to pursue a rhythm control strategy for improvement in quality of life and functional capacity.

47. Pacing for Rhythm Control Values and preferences These recommendations recognize a potential benefit of atrial or dual chamber pacing programmed to minimize ventricular pacing to reduce the probability of AF development following pacemaker implantation.

48. Pacing Mode and AF

49. Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2012*: Catheter Ablation of Atrial Fibrillation and Flutter Atul Verma MD Jafna L Cox MD Laurent Macle MD Allan C Skanes MD *Unchanged from 2010

50. Systematic Review of RCTs Ablation vs Drug Rx AblationControlOR95% CI 28/32 13/35 11.85 3.4-41.4 12/15 6/15 6.0 1.2-30.7 46/53 13/59 23.3 8.5-63.6 85/99 24/99 19.0 9.2-39.3 38/68 6/69 13.3 5.1-34.9 266/344 102/346 15.8 10.1-24.7 • 9 RCTs / 3 systematic reviews in 1274 patients who have failed ≥ 1 drug • uniformly demonstrate large differences in recurrence of AF • (OR 9.74 95% CI, 3.98 to 23.87) in favour of ablation vs AAD Piccini JP et al. Circ Arrhythm 2009;2:626