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Updated guidelines for the treatment of AF 2010.

بسم الله الرحمن الرحيم. Updated guidelines for the treatment of AF 2010. Said Khaled Professor of Cardiology Ain Shams University 2010. First diagnosed episode of atrial fibrillation. Camm et al., AF Guidelines 2010 Eur heart J 2010. AF TREATMENT GOALS.

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Updated guidelines for the treatment of AF 2010.

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  1. بسم الله الرحمن الرحيم Updated guidelines for the treatment of AF 2010. Said Khaled Professor of Cardiology Ain Shams University 2010

  2. First diagnosed episode of atrial fibrillation Camm et al., AF Guidelines 2010 Eur heart J 2010

  3. AF TREATMENT GOALS • Treatment goals in symptomatic pts •  frequency of recurrences •  duration of recurrences •  severity of recurrences • Minimize risk of tachycardia induced cardiomyopathy • Safety is primary concern

  4. AF: TREATMENT OPTIONS Rate control Maintenance of SR Stroke prevention Pharmacologic Nonpharmacologic • Pharmacologic • Warfarin • Thrombin inhibitor • Heparin • Aspirin • Nonpharmacologic • Removal / isolationLA appendage • Pharmacologic • Ca2+ blockers • -blockers • Digitalis • Amiodarone • Nonpharmacologic • Ablate and pace Catheter ablation Surgery (MAZE) Pacing Class IA Class ICClass III -blocker ACE-I ARB Prevent remodeling Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.

  5. Camm et al., AF Guidelines 2010 Eur heart J 2010

  6. His Bundle Ablation Transvenous Permanent Catheter Ablation Ventricular Pacing

  7. AV Node Ablation forAtrial Fibrillation Pro’s Con’s Simple Pacemaker dependence High success Permanent Improved QOL Anticoagulation regular rate controlled rate • Indications • If rate cannot be controlled with pharmacologic agents or tachycardia-mediated cardiomyopathy is suspected, Class IIb, Level of evidence C • If pharmacologic therapy is insufficient or associated with side effects.” Class IIa, Level of evidence C Circulation 2006;114:700-752

  8. AF: TREATMENT OPTIONS Rate control Maintenance of SR Stroke prevention Pharmacologic Nonpharmacologic • Pharmacologic • Warfarin • Thrombin inhibitor • Heparin • Aspirin • Nonpharmacologic • Removal / isolationLA appendage • Pharmacologic • Ca2+ blockers • -blockers • Digitalis • Amiodarone • Nonpharmacologic • Ablate and pace Catheter ablation Surgery (MAZE) Pacing Class IA Class ICClass III -blocker ACE-I ARB Prevent remodeling Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.

  9. AF: TREATMENT OPTIONS Rate control Maintenance of SR Stroke prevention Pharmacologic Nonpharmacologic • Pharmacologic • Warfarin • Thrombin inhibitor • Heparin • Aspirin • Nonpharmacologic • Removal / isolationLA appendage • Pharmacologic • Ca2+ blockers • -blockers • Digitalis • Amiodarone • Nonpharmacologic • Ablate and pace Catheter ablation Surgery (MAZE) Pacing Class IA Class ICClass III -blocker ACE-I ARB Prevent remodeling Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.

  10. Rhythm Control for AF: Commonly Used Oral Antiarrhythmic Drugs Class IA Class IC Class III Quinidine Procainamide Disopyramide Propafenone Propafenone SR Flecainide Sotalol Amiodarone Dofetilide Dronedarone Miller and Zipes. In: Braunwald, et al (eds). Heart Disease. 6th ed. 2001.

  11. AF Efficacy: Maintaining NSR > 6 Months

  12. Camm et al., AF Guidelines 2010 Eur heart J 2010

  13. Combined Results of PIAF, RACE, STAF, and AFFIRM ComparingRate Control versus Rhythm Control 1. Honloser et al. Lancet 356:1789-94, 2000 2. Van Gelder et al. N Engl J Med 347:1834-00, 2002 3. Carlsson et al. J Am Coll Cardiol 41:1690-6, 2003 4. AFFIRM Investigators N Engl J Med 347:1825-33, 2002

  14. Rate Control or Rhythm Control ? • Four trials (PIAF 2, AFFIRM, RACE and STAF) have shown that rate control is not inferior to rhythm control. • A trend toward an even better outcome for rate control therapy is consistent in all studies. Rate control = Rhythm control

  15. AF: TREATMENT OPTIONS Rate control Maintenance of SR Stroke prevention Pharmacologic Nonpharmacologic • Pharmacologic • Warfarin • Thrombin inhibitor • Heparin • Aspirin • Nonpharmacologic • Removal / isolationLA appendage • Pharmacologic • Ca2+ blockers • -blockers • Digitalis • Amiodarone • Nonpharmacologic • Ablate and pace Pacing Catheter ablation Surgery (MAZE) Class IA Class ICClass III -blocker ACE-I ARB Prevent remodeling Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.

  16. Devices for AF: Living Better Electrically N Engl J Med 2002;346(26):2066

  17. 94% of AF triggers from Pulmonary Veins “90 – 95% of all AF is initiated by PV ectopy” Focal Origin of Atrial FibrillationHassaiguerre M, NEJM, 1998 RA LA SVC 17 31 FO Pulmonary Veins 6 11 IVC CS

  18. Lasso™ Guided PV Isolation Before Ablation During Ablation After Ablation I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1 100 ms A PV A A PV

  19. Atrial Fibrillation: Catheter ablation of PV focus The fluoroscopy images show the ablation catheter (ABL) in the left anterior oblique (LAO) and right anterior oblique (RAO) projections.

  20. Left Atrium, Posterior Wall Pulmonary Vein Isolation Nathan, Circ Res, 1969?

  21. Atrial Flutter: Catheter mapping Note sequential activation along the leads of the blue mapping catheter. The yellow ablation catheter is placed in the isthmus between the tricuspid valve and the eustachian valve of the IVC.

  22. Atrial Flutter: Catheter ablation Ablation in the tricuspid isthmus creates a line of block that interrupts the flutter circuit. Subsequent pacing from the coronary sinus demonstrates bi-directional block along the line of ablation.

  23. Catheter ablation vs AAD

  24. Camm et al., AF Guidelines 2010 Eur heart J 2010

  25. Camm et al., AF Guidelines 2010 Eur heart J 2010

  26. Camm et al., AF Guidelines 2010 Eur heart J 2010

  27. APPROACHES TO AF THERAPY Rate control plus anticoagulation preferred • No or lesser AF symptoms • Longer AF Hx • More SHD • Toxicity Risk • Elderly • Greater risk of • proarrhythmia Rhythm control preferred • Greater AF symptoms • Symptoms despite rate control • Younger age • No or lesser SHD • Rx option of class IC AAD In anticoagulation candidates, continue anticoagulation indefinitely

  28. AF: TREATMENT OPTIONS Rate control Maintenance of SR Stroke prevention Pharmacologic Nonpharmacologic • Pharmacologic • Warfarin • Thrombin inhibitor • Heparin • Aspirin • Nonpharmacologic • Removal / isolationLA appendage • Pharmacologic • Ca2+ blockers • -blockers • Digitalis • Amiodarone • Nonpharmacologic • Ablate and pace Catheter ablation Surgery (MAZE) Pacing Class IA Class ICClass III -blocker ACE-I ARB Prevent remodeling Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.

  29. Camm et al., AF Guidelines 2010 Eur heart J 2010

  30. Camm et al., AF Guidelines 2010 Eur heart J 2010

  31. Whats new in AF ttt 2010Transcathete LAA isolation: • WATCHMAN LAA Closure Device • In PROTECT AF, all cause stroke and all cause mortality risk are non-inferior to warfarin 3000838-18

  32. Amplatzer Cardiac (LAA) Plug Design

  33. AF in 2010Conclusions • No marked progress in the pharmaceutical cure of AF. • Dronedarone seems to be effective in AF patients with mild or no HF. • Ablation techniques are not yet recognized as a first line treatment. • If we initiate rhythm control therapy early, Could this result in sloweing progression of AF OR prevent complications ??????

  34. Thank you

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