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Challenges and Controversies in Atrial Fibrillation

Challenges and Controversies in Atrial Fibrillation. Marc J. Girsky, M.D Director Electrophysiology Services Harbor-UCLA Medical Center. Presenter Disclosure Information. Marc Girsky MD St. Jude Medical Corporation – Research projects. Atrial Fibrillation One Patient’s Odyssey.

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Challenges and Controversies in Atrial Fibrillation

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  1. Challenges and Controversies in Atrial Fibrillation Marc J. Girsky, M.D Director Electrophysiology Services Harbor-UCLA Medical Center

  2. Presenter Disclosure Information Marc Girsky MD • St. Jude Medical Corporation – Research projects

  3. Atrial FibrillationOne Patient’s Odyssey • 76 y/o male with Htn, Paroxysmal Afib • 2/2006 – 1st visit • 2005 - 2 Cardioversions, Amiodarone – Recurrent Afib, Increased LFT’s • 3/2006 – 1st Cath ablation – Flecainide 50 BID, increased to 100 mg BID • 1/2007 – Syncope, Amaurosis fugax, start Dofetilide, resume warfarin

  4. One Patient’s Odyssey • 3/2007 – 2nd RFA, continue Dofetilide • 12/2007 – Recurrent Afib Q8 days • 7/2008 – 3rd RFA, continue Dofetilide • 9/2008 – Hematuria, INR – 6 • 10/2009 – D/C Dofetilide, start Dronedarone • 11/2009 – Cerebellar infarct, resume warfarin • 12/2010 – D/C Warfarin, initiate Pradaxa • 3/2011 – Recurrent AFib

  5. Underlying Pathogenesis of Atrial Fibrillation Paroxysmal Persistent Permanent Substrate Initiation substrate Relative importance Trigger AF/disease progression CP1206742-3

  6. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation • ACC/AHA/ESC guidelines prepared over two years: 12 committee members, 4 European, 4 North American electrophysiologists. Updated 2006 • Exhaustive review process based on published literature: evidence-based recommendations and derived from published data. • Strong emphasis on randomized trials: little tolerance for “experience” or anecdotal data

  7. Atrial Fibrillation Management Updates 2006 - Present • 2011 ACCF/AHA/HRS Focused Update • 2010 ESC Atrial Fibrillation Guidelines • 2010 CCS Atrial Fibrillation Guidelines

  8. AFib Management GuidelinesNew Concepts – 2006 - Present • Implications of Rate vs Rhythm control studies for clinical practice • Optimal anticoagulant therapy • Recommendations for catheter based therapies • Introduce the role of angiotensin inhibition in reducing the occurrence and complications of afib • Primary prevention of atrial fibrillation

  9. Anticoagulation Recommendations

  10. AF May Affect Stroke Severity • 1061 patients admitted with acute ischemic stroke • 20.2% had AF • Bedridden state • With AF 41.2% • Without AF 23.7% • Odds ratio for bedridden state following stroke due to AF 2.23 (95% CI, 1.87-2.59; P<.0005) P<.0005 Dulli et al. Neuroepidemiology. 2003;22:118-123.

  11. Major Anticoagulation Trials in Atrial Fibrillation • SPAF1Stroke Prevention in Atrial Fibrillation • BAATAF2 Boston Area Anticoagulation Trial for Atrial Fibrillation • CAFA3 Canadian Atrial Fibrillation Anticoagulation • AFASAK4 Copenhagen Investigators • SPINAF5Stroke Prevention in NonrheumaticAtrial Fibrillation 4 The Lancet. 1989;1:175-178. 5 N Eng J Med. 1992;327:1406-1412. 1 Circulation. 1991;84:527-539. 2 N Engl J Med. 1990;323:1505-1511. 3 J Am Coll Cardiol. 1991;18:349-355.

  12. CHADS2 Score

  13. CHADS2 Score and CVA Risk Gage, B. F. et al. JAMA 2001;285:2864-2870

  14. Anticoagulation Recommendations for Atrial Fibrillation - 2006

  15. Afib GuidelinesOAC Contraindicated Pt • In patients in whom OAC therapy is contraindicated, combination of Plavix and Aspirin is recommended to reduce risk of thromboembolic complications • IIb indication ACC/AHA/HRS Guidelines 2011

  16. CHADS2 VASc Score

  17. CHADS2 VASc Stroke Rate ESC Guidelines 2010

  18. ESC Guidelines – Anticoagulant Tx Lip G Y H et al. Chest 2011;139:738-741

  19. Predicting Bleeding RiskHAS-BLED Score

  20. New Oral Anticoagulants

  21. Cumulative Mortality From Any Cause in the Rhythm-Control Group and the Rate-Control Group No. of Deaths number (%) Rhythm control 0 80 (4) 175 (9) 257 (13) 314 (18) 352 (24) Rate control 0 78 (4) 148 (7) 210(11) 275 (16) 306 (21) AFFIRM Investigators NEJM 2002: 347;23

  22. Study design: Randomized trial comparing rate vs rhythm control • in patients with Afib and EF<35% • 1376 patients from 123 centers • Primary endpoint – Death from cardiovascular causes

  23. Afib and CHF Investigators Primary Endpoint Results NEJM June 2008

  24. Optimal Rate Control TherapyAfib Guidelines Focused Update • Treatment to achieve strict heart rate control (<80 bpm resting, <110 bpm during exercise) is not beneficial compared to achieving a resting heart rate < 110 bpm. • New recommendation

  25. Rhythm Control vs Heart Rate Control “Reasons for restoration and maintenance of sinus rhythm in patients with AF include relief of symptoms, prevention of embolism, and avoidance of cardiomyopathy.” ACC/AHA/ESC AF Guidelines, 2001

  26. Rhythm Control vs Heart Rate Control “An effective method for maintaining sinus rhythm with fewer side effects would address a presently unmet need” ACC/AHA/ESC AF Guidelines, 2006

  27. Symptomatic Atrial Fibrillation!!

  28. Focused GuidelinesMaintaining Sinus Rhythm Wann, L. S. et al. J Am Coll Cardiol 2011;57:223-242

  29. Expectations of Antiarrhythmic Drug Therapy in Treatment of AF • Complete suppression • Best, but AF recurrence likely (>50% of patients) • Recurrence, per se, is not failure of therapy • Frequency of recurrence • More realistic measure of efficacy • May vary from patient to patient

  30. ACE/ARB Antiarrhythmic Properties • Healey, et al JACC 2005 • Meta-analysis of randomized trials involving ACE/ARB • therapy • Included trials if atrial fibrillation events were followed as • endpoints • 11 Trials/56,308 patients – 4 CHF, 3 Htn, 2 post CV, 2 post • MI • Overall risk reduction of AF occurrence 28% (greatest benefit • seen in CHF patients, limited benefit in hypertensive patients)

  31. Curative Ablation for Atrial Fibrillation • Appropriate for Patients • With symptomatic paroxysmal or persistent atrial fibrillation • Who are intolerant of drug therapy • Who have frequent ambient atrial ectopic activity • Who have tachycardia mediated tachycardia

  32. EBCT – Pulmonary Vein/ LA Reconstruction LSPV RIPV LIPV Courtesy: Harbor - UCLA EBCT Center

  33. Pulmonary Vein Circumferential Ablation RSPV Spiral cath

  34. True Pulmonary Vein Isolation

  35. Randomized trial comparing pulmonary vein isolation (41 patients) • to AV node ablation and biventricular pacing (40 patients) • Drug refractory atrial fibrillation and EF <40% • Composite endpoint included QOL questionnaire, 2D-echo follow • up and 6 minute walk distance NEJM 2008;359:1778-85

  36. PABA-CHF InvestigatorsComposite Results NEJM 2008;359:1778-85

  37. PABA-CHF InvestigatorsConclusions • In patients with EF<40% and symptomatic atrial • fibrillation, pulmonary vein isolation was superior • to AV node ablation • In such a population, pulmonary vein isolation should • be considered at experienced centers

  38. A Rational Approach to the Afib Patient What is the pathophysiology of the patient’s Afib? What are the patients symptoms? Will the patient benefit from cardioversion? SR maintenance? Has anticoagulation been considered and implemented? Has the patient failed drug therapy? Invasive strategy considered for pharmacologic failures

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