Atrial Fibrillation: New Ways to Treat an Old Rhythm
Disclosures: None
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Objectives Scope of atrial fibrillation problem? General
information. Negative effects? Stroke Risk Reduction. Oral
anticoagulation*. Device options*. Rate vs. Rhythm Control. Rate
Control*. Rhythm Control. Cardioversion. Medications*. Ablation*.
Practical Management. *: New Treatments
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Epidemiology and Prognosis Most common sustained arrhythmia 2.2
million in US Last 20 years, 66% increase in admissions for a-fib
0.4-1% prevalence (up to 8% in those older than 80) Incidence: 0.1%
per year 80 y/o Prognosis: Increased risk of stroke (5-fold).
Increased risk of heart failure (3-fold). Double mortality rate.
Diminished quality of life. Possible increased risk of
dementia.
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Dementia RiskDementia Risk AF indepenently associated with all
forms of dementia 37025 consecutive patients from large database
followed prospectively. 10161 (27%) developed AF 1535 (4.1%)
developed dementia 5 years follow-up. Mean age 60.617.9 years
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Dementia Risk cont.Dementia Risk cont. AF independently
associated with all dementia. Highest risk of AD was in younger AF
group Dementia patients had higher rates of HTN, CAD, CRI, heart
failure and strokes. After dementia Dx, presence of AF = higher
mortality (HR=1.38-1.45) Bunch et al., Heart Rhythm, 2010, 7:
433.
LAA Occlusion: Amplatzer Cardiac Plug Jain AK, Gallagher S.
Percutaneous occlusion of the left atrial appendage in non-valvular
atrial fibrillation for the prevention of thromboembolism: NICE
guidance. Heart 2011; 97:762.
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LAA Occlusion: Watchman Jain AK, Gallagher S. Technology and
guidelines Percutaneous occlusion of the left atrial appendage in
non-valvular atrial fibrillation for the prevention of
thromboembolism: NICE guidance. Heart 2011; 97:762.
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LAA Occlusion/Amputation. Surgical LAA Amputation
(Garcia-Fernandez et al., Role of left atrial appendage
obliteration in stroke reduction in patients with mitral valve
prosthesis: a transesophageal echocardiographic study, JACC, 2003,
42: 1253) 205 patients studied retrospectively after mitral valve
replacement + LAA amputation. Stroke after 6 years was 3% (vs. 17%
for those without LAA amputation. For the most part, standard of
care at time of mitral valve surgery in patient with h/o atrial
fibrillation. Limited data on stand-alone surgery.
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LAA Occlusion/Amputation. Watchman: Protect AF trial
Non-inferiority, 700 patients randomized 2:1. CHADS score of 1 or
greater. Primary efficacy and primary safety endpoints. Concerns
about safety. Not yet FDA approved. Amplatzer Cardiac Plug Lariat
LAA amputation: some safety data, limited efficacy data.
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Rate and Rhythm ControlRate and Rhythm Control
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What should be driver for deciding between rhythm control and
rate control strategy? 1.Desire to avoid anticoagulation. 2.Alter
long-term prognosis of atrial fibrillation. 3.Control of symptoms
related to atrial fibrillation. 4.All of the above.
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What should be main driver for deciding between rhythm control
and rate control strategy? 1.Desire to avoid anticoagulation.
2.Alter long-term prognosis of atrial fibrillation. 3.Control of
symptoms related to atrial fibrillation. 4.All of the above.
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Randomized, prospective 4060 patients. Rate control (80, 110
bpm) Rhythm control Age: 69.79.9 1 endpoint: overall mortality Mean
f/u 3.5 years Rhythm control associated with more ADRxs,
hospitalizations. AFFIRM:
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Other Rate vs. Rhythm Trials RACE (Hagens et al., JACC, 2004,
43: 241) 522 patients, 689, no difference in composite 1 endpoint.
PIAF (Hohnloser et al, Lancet, 2000, 356: 1789) 252 patients, 6110,
no difference in symptoms. STAF (Carlsson et al., JACC, 2003, 41:
1690) 200 patients, 668, no difference in composite 1 endpoint. HOT
CAF (Opolski et al., Chest, 2004, 126: 476) 205 patients, 6111, no
difference in composite 1 endpoint.
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AF and CHF:AF and CHF: 1376 pts (682 vs. 694) EF 35% CHF
symptoms h/o atrial fibrillation 671 years old (34 pts
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Exceptions to Rate vs. Rhythm Studies? Symptoms, Symptoms,
Symptoms Patient preference. Patient expectation. Atrial
fibrillation contributing/in-setting of other process CHF
especially tachycardia-mediated cardimyopathy. COPD, pneumonia.
Younger age? Average age of previous studies was 61-70. What is
appropriate strategy in younger (
