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41° Convegno CARDIOLOGIA 2007 Milano, 17/21 Settembre 2007

INCONTRI CON GLI ESPERTI. 41° Convegno CARDIOLOGIA 2007 Milano, 17/21 Settembre 2007. LA GESTIONE DELLA FIBRILLAZIONE ATRIALE NEL PAZIENTE CON INSUFFICIENZA CARDIACA: QUANDO CONSERVATIVI , QUANDO AGGRESSIVI. G. Di Tano U.O. Cardiologia Az. Osped . Papardo , Messina.

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41° Convegno CARDIOLOGIA 2007 Milano, 17/21 Settembre 2007

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  1. INCONTRI CON GLI ESPERTI 41° Convegno CARDIOLOGIA 2007Milano, 17/21 Settembre 2007 LA GESTIONE DELLA FIBRILLAZIONE ATRIALE NEL PAZIENTE CON INSUFFICIENZA CARDIACA: QUANDO CONSERVATIVI, QUANDO AGGRESSIVI. G. Di Tano U.O. Cardiologia Az. Osped. Papardo, Messina

  2. Unadjusted cumulative incidence of first AF in individuals with CHF Unadjusted cumulative incidence of first CHF in individuals with AF Wang TJ et al. Circulation 2003;107:2920

  3. ATRIAL FIBRILLATION : PREVALENCE INCREASE WITH SEVERITY OF HEART FAILURE Camm AJ et al. Dialog Cardiovasc Med, 2003

  4. Heart Failure LA pressure Angiotensin II Aldosterone Atrial Fibrosis Atrial Remodeling Stretch sympathetic tone Ectopic activity Atrial Fibrillation

  5. Types of AF Triggers ectopic foci Paroxysmal AF Electrophysiologic Remodeling Chronic Substrate fibrosis Persistent AF Permanent AF Stambler et al JCE 2003;14:499Li, Nattel et al. Circulation. 1999;100:87-95

  6. Heart Failure LA pressure Angiotensin II Aldosterone Rapid Rate Atrial Fibrosis Irregular R-R Intervals Atrial Remodeling Loss of atrial contraction Stretch sympathetic tone Ectopic activity Atrial Fibrillation

  7. Rapid heart rates depress contractility: abnormal force - frequency in relationship in heart failure 200 Nonfailing Failing 100 % change in Force 0 20 60 120 180 Heart Rate (beats / min) Pieske Circ Res 1999; Gwathmey JCI 1990; Mulieri Circulation 1992; Heerdt PM, Circulation. 2000;102:2713-9.

  8. Atrial Fibrillation and Tachycardia Induced Cardiomyopathy • Cardiomyopathy can be caused by any tachycardia (>110 bpm) that occurs as little as 10-15% of day • Severity related to rate and duration of  HR • Maximal improvement after rate control may require upto 8 months • After improvement susceptibility to rapid deterioration remains if tachycardia recurs Olshansky et al Circulation 2004 Fenelon et al PACE 1996; 19:95-106 Shinbane J et al. JACC 1997; 29: 709-715

  9. Gestione della Fibrillazione Atriale nello Scompenso Cardiaco GESTIONE APPROCCIO CONSERVATIVO... TERAPIA OTTIMIZZATA DELLO SCOMPENSO APPROCCIO AGGRESSIVO…

  10. Prevention of Atrial Fib With Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: A Meta-Analysis Healey, et al JACC 2005;45:1832 • 11 studies with 56,308 patients • Overall, ACEIs and ARBs reduced the relative risk of AF by 28% • Benefit is similar for ACE-inhibitors and AII blockers • Reduction in AF was greatest in patients with heart failure (relative risk reduction 44%, p = 0.007). • There appears to be a large effect after cardioversion (48% RRR), but the confidence limits are wide (95% CI 21% to 65%)

  11. Atrial Fibrillation in Patients with Heart Failure: Management • Rate control • Anticoagulation • Rhythm control = restore sinus rhythm or • Rate control = remain in fibrillation

  12. Atrial Fibrillation: Rate Control • digoxin – poor efficacy but well tolerated • beta - adrenergic blockers • calcium channel blockers – effective but negative inotropic effects • verapamil, diltiazem • amiodarone – effective but potential major toxicity

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  14. Atrial Fibrillation + Heart Failure Rhythm Control (restore and maintain sinus rhythm) Rate Control ? Avoidance antiarrhythmic drugs… Reduced need for repeated CVE Improved cardiac function and symptoms Improved QL Prevention TE

  15. Atrial Fibrillation in Heart Failure • Patients with AF have increased mortality compared to SR patients • Patients who convert to SR have lower mortality than those who remain in AF Should patients with heart failure and AF be converted and maintained in sinus rhythm? Wang Circ 2003;107:2920; MiddlekauffCirc 1991; 84: 40 Dries JACC. 1998; 32: 695; DeedwaniaCirc 1998; 98: 2574; PozzoliJACC 1998; 32: 197; Torp-Pedersen NEJM 1999; 341: 857

  16. AFFIRM PIAF RACE STAF Rhythm Control “ If you were born in sinus rhythm, you should probably try to remain so”. Rate Control

  17. AFFIRMA Comparison of Rate Control and Rhythm Control in Patients with Atrial FibrillationNEJM 347:1825, 2002 • 4060 patients (age 70 yrs) • Mortality at 5 yrs (p = 0.06): rhythm control 23.8% vs 21.3% rate control • Rhythm control (RS only in 63%) • increased hospitalizations • increased exposure to drug adverse effects • did not reduce strokes • did not improve functional capacity or quality of life • Most strokes occurred after warfarin had been stopped or was subtherapeutic

  18. AFFIRM was not a Heart Failure Trial Prior CHF: 23.1% Mean EF: 55% “Normal” LV ejection fraction in 74% - 939 HF pts: no benefit of a strategy of rhythm control. - Presence of RS carried a small, but statically significant, improvement in NYHA functional class at follow-up. Chung MK et al, J Am Coll Cardiol 2005;46:1891

  19. Is rhythm control superior to rate control in patients with atrial fibrillation and congestive heart failure? Al-Khatib SM et al., Am J Cardiol 2004;94:797 In 1,009 patients with AF and congestive heart failure, the 1-year mortality rate was identical (both 21%) and at 2-year mortality rate was 31% in patients treated with rate control (n = 505) versus 29% in patients treated with rhythm control (n = 504). After adjusting for differences in baseline characteristics and medications, no significant difference in mortality was found between the 2 groups (p=.79)

  20. Am Heart J 2005:149;1106

  21. Motivi della mancata efficacia della strategia Rhythm control • Effetto deleterio degli antiarimici(minor efficacia, azione proaritmica - aritmie ventricolari, aumentato FCV durante AF, bradiaritmie - , inotropi negativi, tossicità) • Interazioni farmacologiche • Conversione di episodi di FA sintomatici in episodi “silenti” … • Sospensione anticipata TAO Class I antiarrhythmic drugs increase mortality in patients with heart failure and AF - (post-hoc analysis) SPAF, JACC 1992

  22. Rate Control vs Rhythm Control • Favor rate control • Asymptomatic, old, pts in atrial fibrillation • Contraindication to amiodarone • Favor attempts to maintain sinus rhythm • First or infrequent episodes of persistent AF • Significant symptoms in AF • Difficult rate control • Contraindication to long term warfarin

  23. Class I anti-arrhythmic drugs should be avoided as they may provoke fatal ventricular arrhythmias, have an adverse hemodynamic effect and reduce survival in heart failure Level of evidence B, class III

  24. BackgroundAmiodarone is effective in maintaining sinus rhythmin atrial fibrillation but is associated with potentially serioustoxic effects. Dronedarone is a new antiarrhythmic agent pharmacologicallyrelated to amiodarone but developed to reduce the risk of sideeffects. Methods In two identical multicenter, double-blind, randomizedtrials, one conducted in Europe and one conducted in the United States, Canada,Australia, South Africa, and Argentina , we evaluated the efficacy of dronedarone,with 828 patients receiving 400 mg of the drug twice daily and409 patients receiving placebo. Rhythm was monitored transtelephonicallyon days 2, 3, and 5; at 3, 5, 7, and 10 months; during recurrenceof arrhythmia; and at nine scheduled visits during a 12-monthperiod. The primary end point was the time to the first recurrenceof atrial fibrillation or flutter. ResultsIn the European trial, the median times to the recurrenceof arrhythmia were 41 days in the placebo group and 96 daysin the dronedarone group (P=0.01). The corresponding durationsin the non-European trial were 59 and 158 days (P=0.002). Atthe recurrence of arrhythmia in the European trial, the mean(±SD) ventricular rate was 117.5±29.1 beats perminute in the placebo group and 102.3±24.7 beats perminute in the dronedarone group (P<0.001); the correspondingrates in the non-European trial were 116.6±31.9 and 104.6±27.1beats per minute (P<0.001). Rates of pulmonary toxic effectsand of thyroid and liver dysfunction were not significantlyincreased in the dronedarone group. Conclusions Dronedarone was significantly more effective thanplacebo in maintaining sinus rhythm and in reducing the ventricularrate during recurrence of arrhythmia. ANDROMEDA: Trial in pz con SC interrotto per > rischio di mortalità nei trattati 18% dei pz era in classe NYHA I - II III - IV classe esclusi

  25. OTTIMIZZAZIONE DELLA CARDIOVERSIONE ELETTRICA ESTERNA PLACCHE ANTERO-POSTERIORE SHOCK BIFASICO (energie minori; a 150 J successo >90%) AMIODARONE 400 mg/die, 1 mese prima e 1-2 mesi dopo CVE: aumenta percentuale di RS e recidive FA a 1m CONTROINDICAZIONI:No TAO Temporanee: Trombosi atriale Terapia digitalica Ipertiroidismo…

  26. IPERTIROIDISMO SUB-CLINICO E FIBRILLAZIONE ATRIALE • Bassa concentrazione di TSH (-soppresso-, < 0.01 µIU/ml) con normali livelli di FT3 e FT4 , in pazienti asintomatici. • Prevalenza dell’11.8% tra gli anziani (0.5% - 3.9% negli adulti) • Framingham (< 65 a): a 10 anni: - FA nel 28% in pz con SCHyp 11% nei normali Sawin CT, Thyroid 2002

  27. Cosa mi aspetta al rientro… • Uomo, 57 anni, professionista, senza FR, CMD primitiva • 01/04: insorgenza SC con FA ad elevata FCVm, BBSn, NYHA III; • ECO: FE 25%, ipocglob; DTD 62mm; IM ++, IT+++, dilatazione biatriale. • Terapia: diuretici, ace-i; digitale; TAO. Migliorato, - 8 Kg, BNP in calo • 03/04: Ricovero: coronarie normali, biopsia (neg); ECO: FE 30%, IM +; • I T++, RS dopo CVE; profilassi con amiodarone ; inizia carvedilolo. • - Ipotensione sintomatica: sospende ace-i; passa a bisoprololo • - Progressiva stabilità. BNP 230 • 07/04: Ipertiroidismo iatrogeno. Sospende amiodarone. Resta in TAO • - ECO: FE 35%, DTD: 58mm; AS: 19cm2. • 02/05: Stabile; NYHA 1-2; Ormoni tiroidei normali; ECO: FE 35-40%, TAO

  28. 12/06: Recidiva FA. (cardiopalmo, dispnea lieve…) , BNP 373 • 01/07: CVE efficace (shock bifasico, 75J): RS. Terapia confernata… • 06/07: Stabile; ECO: FE 38%,DTD 54mm, AS:42mm, AD:23cm2, IM+, IT+; BNP 250. • 07/07: Riscontro occasionale di recidiva FA (60 b/m); asintomatico, BNP = • 08/07: Persiste FA (FVm: 58b/m); asintomatico; non dispnea da sforzo. • 09/07: Astenia, dispnea da sforzo… . Cosa fare ?

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