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Atrial fibrillation: 2011 Updates

Atrial fibrillation: 2011 Updates. Atrial Fibrillation. www.washingtonhra.com. The Scope of the Problem. 3 million Americans 160,000 new cases each year 16 million by 2050 90% of patients have recurrences Incremental cost = $26 billion. JACC 2004; 43(1): 47-52.

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Atrial fibrillation: 2011 Updates

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  1. Atrial fibrillation:2011 Updates

  2. Atrial Fibrillation www.washingtonhra.com

  3. The Scope of the Problem • 3 million Americans • 160,000 new cases each year • 16 million by 2050 • 90% of patients have recurrences • Incremental cost = $26 billion JACC 2004; 43(1): 47-52. Circ 2006; 114: 119-125. Circ Cardiovasc Qual Outcomes 2011; 4(3): 313-20.

  4. RATE CONTROL RHYTHM CONTROL STROKE PREVENTION

  5. Question 1 An 84 year old woman with HTN presents for routine follow-up of long-standing atrial fibrillation. She is active and asymptomatic. She is on Toprol 100 mg daily and warfarin. Her resting HR is irregular and 97, blood pressure 110/68. Her exam is otherwise normal. What should you do next? A. Continue current therapy. B. Increase her Toprol to 150 mg daily. C. Start dronedarone 400 mg bid. D. Add digoxin 0.125 mg daily. E. Refer for DCCV.

  6. Question 1 An 84 year old woman with HTN presents for routine follow-up of long-standing atrial fibrillation. She is active and asymptomatic. She is on Toprol 100 mg daily and warfarin. Her resting HR is irregular and 97, blood pressure 110/68. Her exam is otherwise normal. What should you do next? A. Continue current therapy. B. Increase her Toprol to 150 mg daily. C. Start dronedarone 400 mg bid. D. Add digoxin 0.125 mg daily. E. Refer for DCCV.

  7. Rate Control • Rest heart rate ≤ 80 bpm. • 24-hr Holter average ≤ 100 bpm. • 6-min walk HR ≤ 110 bpm. NEJM. 347(23): 2002.

  8. 614 patients with permanent atrial fibrillation • Strict vs. lenient rate control: • < 80 bpm vs. < 110 bpm • Noninferiority trial • 1˚ EP: death from cardiovascular causes, hospitalization from CHF, CVA, systemic embolization, bleeding and life threatening arrhythmic events • Follow-up: 2-3 years

  9. Avg HR: 94±9 vs. 76±12 Dyspnea, fatigue or palpitations 45.6% vs. 46.0%

  10. Paroxysmal <7 days Persistent >7 days Permanent >12 months

  11. Question 2 A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next? A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement. C. Start dronedarone 400 mg bid. D. Cardiovert and refer for catheter ablation (pulmonary vein isolation).

  12. Question 2 A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next? A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement. C. Start dronedarone 400 mg bid. D. Cardiovert and refer for catheter ablation (pulmonary vein isolation).

  13. Question 2 A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next? A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement. C. Start dronedarone 400 mg bid. D. Cardiovert and refer for catheter ablation (pulmonary vein isolation).

  14. Dronedarone (Multaq)

  15. 1˚ EP (recurrence or premature study drug discontinuation): 74% vs 55% • Atrial fibrillation recurrence 63.5% vs. 42% • Premature discontinuation 10.4% vs. 13.3% J Cardiovasc Electrophysiol 2010; 21: 597-605.

  16. DAFNE: to determine the most appropriate loading dose for prevention of AF after DCCV Freedom from Atrial Fibrillation

  17. Resting HR Exertional HR

  18. 4628 patients: dronedarone 400 mg bid vs placebo • 1˚ EP: 1st hospitalization due to CV events or death • Mean f/u 21 months • Rx discontinuation: 30.2% vs 30.8% > 70 years old hypertension diabetes mellitus prior TIA/CVA/embolization LA diameter ≥50 mm LVEF ≤ 40%

  19. Multi-national, RDBPC trial comparing placebo to dronedarone in patients with permanent atrial fibrillation • Inclusion criteria: > 65 years old with history of embolization, myocardial infarction, ASCAD, prior CHF or >75 years old/HTN/DM. • Exclusion criteria: class IV or unstable class III CHF • Composite endpoint: MACE (stroke, systemic arterial embolization, MI, cardiovascular death), cardiovascular hospitalization and all-cause mortality

  20. Target enrollment: 10,800 patients • Stopped at 3149 patients significant increase in cardiovascular events in patients taking dronedarone (Permanent Atrial fibriLLAtion outcome Study using dronedarone)

  21. Hypothesis: Dronedarone will reduce the rate of hospitalization due to heart failure and possibly also reduce mortality by reducing arrhythmia. • Inclusion Criteria: • Class III-IV CHF or PND with LVEF ≤ 35% • Exclusion Criteria: • Acute pulmonary edema <12 hours prior • Recent myocardial infarction • Planned or recent cardiac surgery or angioplasty

  22. Planned enrollment: 1000 patients • Terminated after a median follow-up of 2 months HR 2.13; 95% CI: 1.07 to 4.25, p =0.03

  23. Question 2 A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next? A. Titrate heart failure medications, nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement. C. Start dronedarone 400 mg bid. D. Cardiovert and refer for catheter ablation (pulmonary vein isolation).

  24. Question 2 A 52 year old man with atrial fibrillation and mild LV systolic dysfunction presents with recurrent atrial fibrillation and heart failure despite multiple attempts at DCCV followed by trials of dofetilide and amiodarone. Vitals: HR 68, BP 120/80 . What should you do next? A. Titrate heart failure medications , nothing further can be done for the atrial fibrillation. B. Refer for AV node ablation and pacemaker placement. C. Start dronedarone 400 mg bid. D. Cardiovert and refer for catheter ablation (pulmonary vein isolation).

  25. …... www.atrialfibrillationablation.org

  26. Pulmonary Vein Isolation

  27. Pulmonary Vein Isolation www.aafp.org

  28. CABANA • Multicenter, prospective, randomized, open-label clinical trial • Hypothesis: Percutaneous LACA for the purpose of eliminating atrial fibrillation is superior to current state-of-the-art therapy with either rate control or rhythm control drugs. • Inclusion criteria: paroxysmal or persistent atrial fibrillation with stroke/TIA or one or more risk factors • 1˚ Endpoint: total mortality • Follow-up: minimum of 2 years

  29. Question 3 A 76 year old male with HTN and diabetes presents with the new diagnosis of atrial fibrillation, discovered on a preoperative EKG for cataract surgery. He is active and asymptomatic. Medications include Toprol and Metformin. His resting heart rate is well controlled. What do you advise to decrease his risk for stroke? A. No additional treatment is necessary. B. Start ASA 325 mg daily. C. Start ASA 81 mg daily and Plavix 75 mg daily. D. Begin warfarin. E. Jantoven, dabigatran or rivaroxaban should be started.

  30. otm.oxfordmedicine.com www.med.umich.edu

  31. Question 3 A 76 year old male with HTN and diabetes presents with the new diagnosis of atrial fibrillation, discovered on a preoperative EKG for cataract surgery. He is active and asymptomatic. Medications include Toprol and Metformin. His resting heart rate is well controlled. What do you advise to decrease his risk for stroke? A. No additional treatment is necessary. B. Start ASA 325 mg daily. C. Start ASA 81 mg daily and Plavix 75 mg daily. D. Begin warfarin. E. Jantoven, dabigatran or rivaroxaban should be started.

  32. Low risk = ASA High Risk = AC Who Gets Long Term Anticoagulation?

  33. Who Gets Long Term Anticoagulation? * *Vascular disease = prior MI, aortic plaque or peripheral vascular disease Anticoagulation for scores ≥ 2

  34. 1° Endpoint: stroke, systemic embolization, myocardial infarction or vascular death

  35. Hypothesis: The addition of clopidogrel to ASA will reduce the risk of vascular events. • 1° Endpoint: stroke, systemic embolization, myocardial infarction or vascular death

  36. 7,554 patients, median follow-up 3.6 years • 1° Endpoint: stroke, systemic embolization, myocardial infarction or vascular death

  37. FDA Press Release FDA NEWS RELEASE : 19 OCT 2010 FDA approves Pradaxa to prevent stroke in patients with ATRIAL FIBRILLATION

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