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Réduction de la Fibrillation Auriculaire en Pratique de Ville

Samer Nasr, M.D. Mount Lebanon Hospital. Réduction de la Fibrillation Auriculaire en Pratique de Ville. Classification. Lone atrial fibrillation: Younger than 60 years old. No clinical or echo evidence of cardiopulmonary disease. Favorable prognosis.

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Réduction de la Fibrillation Auriculaire en Pratique de Ville

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  1. Samer Nasr, M.D. Mount Lebanon Hospital. Réduction de la Fibrillation Auriculaire en Pratique de Ville

  2. Classification • Lone atrial fibrillation: • Younger than 60 years old. • No clinical or echo evidence of cardiopulmonary disease. • Favorable prognosis. • Thromboembolism usually not an issue. • Substrate related atrial fibrillation. • ETOH Hyperthyroidism HTN • Surgery Metabolic disorders Cardiomyopathy • MI Obesity Sleep apnea • PericarditisValvular disease • Myocarditis Heart failure • PE CAD

  3. Substrate Related Atrial Fibrillation.

  4. Substrate Related Atrial Fibrillation.

  5. Substrate Related Atrial Fibrillation.

  6. AF: Treatment Options Rhythm normalization Stroke prevention Rate normalization Anti – coagulation INR: 2-3 • AV node blockers BB - • DIG • CA - • … • AV node ablation • AA drugs • Ia • Ic • III • New AAd • Cardioversion • Non AA drugs • AF Ablation • Pharmacologic • AC ++ Aspirin • New AT drugs • Nonpharmacologic • Removal/isolation LA appendage

  7. Lone Atrial Fibrillation:Outpatient Conversion to NSR.

  8. Lone Atrial Fibrillation • Rate of progression to permanent atrial fibrillation. • Prognosis

  9. LoNE First Episode Paroxysmal (recurrent) No recurrence Permanent

  10. Probability of AF recurrence after the first episode 757 patients the Canadian Registry of Atrial Fibrillation Am Heart J 2005;149:489- 96

  11. Progressing to chronic AF after the first episode 525 patients UK Registry . BMC Cardiovascular Disorders 2005, 5:20

  12. Long-term progression of paroxysmal or persistent lone AF to permanent AF 30-Year Follow-Up Olmsted County Circulation. 2007;115:3050-3056

  13. => Up to 30% of patients will not recur their AF after the first episode => the risk of progression to permanent atrial fibrillation is around 20% in young patients

  14. Mortality rate in paroxysmal atrial fibrillation 525 patients 5 y F-U * Relative risk estimated by Cox regression model, including age, sex, smoking, heart failure, ischaemic heart disease, hypertension, cerebrovascular disease and diabetes. UK Registry BMC Cardiovascular Disorders 2005, 5:20

  15. Long-term observed survival in lone AF 30-Year Follow-Up Olmsted County Circulation. 2007;115:3050-3056

  16. =>Patients with lone atrial fibrillation have a normal life expectancy. =>Comorbidities significantly modulate AF prognosis and complications: hypertension, diabetes, heart failure, and advancing age …

  17. Long term efficacy of Anti-arrhythmic drugs

  18. 100 Amiodarone (n = 201) 80 60 Propafenone (n = 101) Patients Without Recurrence (%) 40 Sotalol (n = 101) 20 0.0 0 100 200 300 400 500 600 Days of Follow-up CTAF Study: % of Patients Remaining Free of Recurrence of AF Roy D, et al. New Engl J Med. 2000;342:913–920.

  19. Adverse Effects of Oral Amiodarone Zimetbaum P. N Engl J Med 2007;356:935-941

  20. Treatment of Paroxysmal Atrial Fibrillation in Outpatient Setting. • Out patient management of PAF can be performed using: • Pill-in- the-pocket. • Amiodarone. • Dronaderone.

  21. Pill-in-the-pocket • A beta-blocker or NDHP Ca-blocker. • Half an hour later ; if symptoms persist: • Propafenone: • 600 mg if > 70kg • 450mg if <70 KG • Flecanide: • 300 mg if >70 kg. • 200 mg if < 70 kg. • Only once in 24 hour period.

  22. Pill-in-the-Pocket • 268 patients presenting to ER with AF. given Flecanide or Propafenone. • 58 had treatment failure or side effects; excluded • Out-of-Hospital self administration of Flecanide or Propafenone studied in remaining 210. • 79 percent had episodes of arrhythmias • 92 % treated 36±93 minutes after sx onset • Treatment succesful in 94% of episodes. • Alboni P, et al. NEJM, 2004;351:23.

  23. “Pill in the Pocket” Technique episodes per month 80 ns 70 P < 0.001 59.8 60 54.5 45.6 50 40 P < 0.001 30 15 20 4.9 10 1.6 0 Paroxysms of AF Emergency visits Hospitalizations Previous year Pill in the Pocket treatment period Alboni P, et al. N Engl J Med.2004;351:2384-2391.

  24. … For additional safety • Treat the first episode inpatient with IC antiarrhythmics. • Make sure QT interval stays unchanged with therapy. • Perform exercise stress test on therapy and document QRS interval stability prior to initiating pill-in-the-pocket technique.

  25. Lone Atrial Fibrillation • Outpatient therapy of Lone AF can be performed safely and effectively if thorough patient selection with appropriate work up is performed. • QOL is The main goal of outpatient therapy.

  26. Amiodarone in Outpatient Setting Dosages and precautions

  27. Electrophysiological Action of Amiodarone Zimetbaum P. N Engl J Med 2007;356:935-941

  28. Recommendations • Baseline screening studies should include tests of liver, thyroid, and pulmonary function as well as chest radiography. • It is reasonable to initiate amiodarone therapy in the outpatient setting.

  29. Recommendations • A slightly reduced loading dose (e.g., 600 mg per day in one dose or divided doses for 3 to 4 weeks) is reasonable. • The patient should undergo electrocardiography weekly or should be discharged with a loop recorder to monitor heart rhythm, heart rate, and duration of the QT interval. • If conversion has not occurred by the end of the loading period, electrical cardioversion should be performed, followed by a reduction in the dose of amiodarone to 200 mg daily.

  30. The ATHENA Trial A placebo-controlled, double-blind, parallel arm Trial to assess the efficacy of dronedarone 400 mg bid for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation / atrial flutter ATHENA study Hohnloser. N Engl J Med 2009;360:668-78.

  31. 7.5 HR=0.71 P=0.034 Placebo 5.0 Dronedarone Cummulative Incidence (%) 2.5 0.0 Months 0 6 12 18 24 30 Patients at risk Placebo 2327 2290 2250 1629 636 7 Dronedarone 2301 2274 2240 1593 615 4 Dronedarone reduces Cardiovascular Death ATHENA study Hohnloser. N Engl J Med 2009;360:668-78.

  32. 50 HR=0.76 Placebo P<0.001 40 Dronedarone 30 Cummulative Incidence (%) 20 10 0 Months 0 6 12 18 24 30 Patients at risk Placebo 2327 1858 1625 1072 385 3 Dronedarone 2301 1963 1776 1177 403 2 Dronedarone reduces the incidence of cardiovascular hospitalization or death ATHENA study Hohnloser. N Engl J Med 2009;360:668-78.

  33. Dronaderone vs Amiodarone • Meta-analysis on Dronaderone vs Amiodarone: From ANDROMEDA to. DIONYSOS. • Dronaderone less effective than amiodarone for atrial fibrillation with an odds ratio of 0.5 . • Less Side Effects. • Less efficacy. • Dronaderone trades efficacy for safety. • Piccini et al, J. Am Coll Cardiol. 2009: 54:1089-1095

  34. Conclusion: • Lone atrial fibrillation: a benign disease. • Strict rules should apply to outpatient therapy. • Careful initial screening for underlying heart disease is imperative. • Frequent reevaluation of the substrate is a must to ensure that organic heart disease has not occurred with time.

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