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Atrial Fibrillation-Current Evaluation and Management PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Atrial Fibrillation - Current evaluation and management" by Prabhat Hebbar, MD.

This medical PowerPoint presentation talks about evaluation and management atrial fibrillation.

Atrial fibrillation (AF) is a common heart rhythm disorder characterized by irregular and often rapid heartbeats. It is estimated to affect more than 33 million people worldwide, and its prevalence is expected to increase as the population ages.

The current evaluation of AF includes a thorough medical history and physical examination, electrocardiogram (ECG), echocardiogram, and laboratory tests. Additional testing may include Holter monitoring or event recording to capture intermittent episodes of AF.

The management of AF depends on several factors, including the patients age, symptoms, and comorbidities. The main goals of treatment are to control the heart rate, prevent blood clots and stroke, and restore and maintain normal sinus rhythm.

Tags : Atrial Fibrillation, electrocardiogram, ECG, echocardiogram, laboratory tests, cardiology

Published on : Mar 17, 2023 | Views : 1531 | Downloads : 8

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Slide 1-

Atrial Fibrillation Current evaluation and management -Prabhat Hebbar MD.
Slide 2-

Epidemiology
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CDC Fact Sheet 2017 2.7–6.1 million people in the United States have AFib. 2% of people age < 65, 9% of people age > 65 years have AFib African Americans are less likely to have AFib. women generally live longer than men, more women than men experience AFib. Cost and Consequences 750,000 hospitalizations/year. 130,000 deaths/year. Cost: $6 billion/year. AFib causes 15%–20% of ischemic strokes
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-Miyasaka et al; Circulation 2006;114:119–125 Overall and sex-specific trends in incidenceof AF between 1980 and 2000
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Stroke risk related to various cardiac conditions Framingham study - Wolf et al. Stroke 1991;22:983–988.
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Outcomes Mortality: doubled Stroke: increased 5 fold. More severe Hospitalization: more frequent Quality of life: wide variation, from no change to marked reduction. Congestive heart failure: wide variation from none to severe(tachymyopathy)
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Mechanisms of AF
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Electrophysiological mechanisms Triggers for onset + Substrate for maintenance Triggers mechanism: triggered activity and re-entry most common site: pulmonary veins - shorter refractory periods - abrupt changes in myocyte fiber orientation. paroxysmal AF: the junction between the PVs and the left atrium.
Slide 10-

Triggers Haïssaguerre M et al. N Engl J Med 1998;339:659-666.
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Substrate Sustained atrial fibrillation triggers an inflammatory response leading to activation of myofibroblasts and release of cytokines - development of fibrosis - myocyte apoptosis - extracellular matrix generation and turnover - electrical and structural remodeling provides substrate for maintenance of to atrial fibrillation
Slide 12-

Persistent Atrial Fibrillation
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Natural History
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Evaluation and Management
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Detection An irregular pulse or irregular heart beat on auscultation should raise suspicion ECG is necessary to diagnose AF. Any arrhythmia that has the ECG characteristics of AF and lasts sufficiently long for a 12-lead ECG to be recorded, or at least 30 s on a rhythm strip, should be considered as AF. Holter (24-48 hrs) Event monitors (upto 1 month) Dual chamber pacemakers and defibrillators. Implantable loop recorder (upto 3 yrs)
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Evaluation and Management Acute management: - relief of symptoms - assessment of AF-associated risk. Clinical Evaluation: Detailed history to assess - CHADs-2VaSC score/Stroke risk. - bleeding risk - time of onset (48 hrs) - conditions predisposing to AF - complications of AF
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Testing EKG, Holter and event monitors Labs: CBC, BMP, TSH, +/- LFTs Echo: valvular, ventricular, atrial and congenital heart diseases, LA dimensions. Stress test: reasonable if signs/risk factors for CAD
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Management Goals Reduce symptoms - rate vs rhythm control - cardioversion Preventing severe complications - anticoagulation - control of ventricular rate - adequate therapy of concomitant cardiac diseases
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Management Cascade
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Anticoagulation
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Anticoagulation AF increases the risk of stroke by five-fold Stroke in atrial fibrillation more disabling. Anticoagulation reduces stroke risk by two-thirds Anticoagulation only treatment shown to reduce mortality in AF Antiplatelet therapy reduces stroke risk by one-fifth
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CHADS2 Score Evolved from the AF investigators and SPAF investigators criteria. Initial rapid and easy to use means of assessing stroke risk. CHADS2 score of 0, an adjusted rate of 1.9 per 100 pt yrs Stroke rate increased by a factor of 1.5 for each 1-point Recommendations low risk (score 0): No anticoagulation moderate risk (score 1) Aspirin or oral anticoagulation high risk (score >/= 2) Oral anticoagulation - Gage et al, JAMA. 2001;285:2864 2870
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CHADS2 Score limitations Too many patients classified as moderate risk Even pt at mod risk (CHADs 2 =1) benefit from anticoagulation over aspirin Did not include many stroke risk factors
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CHA2DS2-VASc Score Lip et al, Chest 2010;137:263–272
Slide 25-

“And there’s an app for that too”
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Recommendations CHA2DS2-VASc score of 0, reasonable to omit antithrombotic therapy. CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. CHA2DS2-VASc score of 2 or greater, oral anticoagulants are recommended CHA2DS2-VASc score of 2 or greater and who have end-stage CKD (CrCl <15 mL/min) or are on hemodialysis, it is reasonable to prescribe warfarin (INR 2.0 to 3.0) for oral anticoagulation.
Slide 27-

Hart et al, Ann Intern Med. 2007;146:857-867
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Adjusted dose warfarin vs placebo/control - Hart et al, Ann Intern Med. 2007;146:857-867 64%
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Hart et al Stroke reduction Warfarin: 64% (95% CI, 49% to 74%) absolute risk reduction: 2.7% per year Aspirin: Nonsignificant 19% (CI, -1% to 35%) absolute risk reduction: 0.8% per year Warfarin vs antiplatelet therapy: 37% (CI, 23% to 48%) Major Bleeding warfarin vs aspirin: risk for intracranial hemorrhage doubled absolute risk increase small (0.2% per year) Mortality warfarin versus control: all-cause mortality substantially reduced (26% [CI, 3% to 43%])
Slide 30-

NoACs vs Warfarin Limited reversal agents
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Dabigatran Direct Thrombin Inhibitor Alternative to warfarin for CHADS2VaSc of 2 or greater in those with nonvalvular afib RE-LY Trial: 150 mg dose superior to warfarin in preventing ischemic stoke with no difference in bleeding Praxbind ® (idarucizumab) is a specific reversal agent for Pradaxa
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RELY
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Rivaroxaban Oral factor Xa inhibitor Rocket AF: noninferior to warfarin for stroke prevention no significant difference in risk of major bleeding intracranial and fatal bleeding occurred less frequently Antidote: FDA approves AndexXa
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Rocket AF
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Apixaban Oral factor Xa inhibitor Aristotle : superior to warfarin in preventing stroke caused less bleeding resulted in lower mortality Antidote: FDA approves AndexXa Dose Adjustment: Cr >1.5, Age > 80, Wt < 60 kgs
Slide 36-

Aristotle
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Edoxaban Edoxaban: ENGAGE AF study Oral factor Xa inhibitor edoxaban 30 mg and 60 mg vs Warfarin noninferior to warfarin with respect to the prevention of stroke or systemic embolism significantly lower rates of bleeding and death from cardiovascular causes
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Cardioversion
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Cardioversion
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Cardioversion Short duration < 48 hrs – No prior anticoagualtion (AC) required. Duration > 48 hrs - need 3 weeks of (AC) or TEE. All patients need 4 weeks of AC post cardioversion DC cardioversion (100-200J synchronized shock) Pharmacological cardioversion (Ibutilide, Flecainide, Propafenone, Amiodarone) Pill in the Pocket Strategy: Flecainide or Propafenone Ibutilide: 1mg over 10 min may repeat x 1, check EKG QTc < 480, Echo EF > 20%, all pts get 2 gm of Mg prior.
Slide 42-

RATE VS Rhythm Control
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Rate vs Rhythm control trials Rhythm-control strategy offers no survival advantage over rate-control. Lower risk of adverse drug effects, with the rate-control strategy. Anticoagulation should be continued in this group of high-risk patients.
Slide 44-

Outcomes Mortality and hospitalization: - No benefit of rhythm control - Post-hoc analysis: maintenance of sinus rhythm improves survival Quality of Life: - No differences in quality if life . - Post-hoc analyses: maintenance of sinus rhythm may improve quality of life. Ideal patient for rate control: Elderly patient with asymptomatic atrial fibrillation.
Slide 45-

Sinus Rhythm associated with decreased risk of death (HR 0.53). Warfarin use associated with decreased risk of death (HR 0.50) AADs associated with increased mortality only after adjustment for the presence of SR(HR1.49). AADs are not associated with improved survival, which suggests that any beneficial antiarrhythmic effects of AADs are offset by their adverse effects. If an effective method for maintaining SR with fewer adverse effects were available, it might be beneficial.
Slide 46-

RACE II Trial 614 pts with permanent AF Lenient rate control: resting heart rate <110 bpm in AF Strict rate control: resting heart rate of <80 bpm and an adequate increase in heart rate upon moderate exertion Lenient rate control is as effective as strict rate control and is easier to achieve Symptoms, adverse events, and quality of life similar in both groups. Patients assigned to lenient rate control had fewer hospital visits.
Slide 47-

Optimal rate control
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Rhythm Control
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Principles of antiarrhythmic drug(AAD) therapy Treatment is to reduce AF-related symptoms. Efficacy to maintain sinus rhythm is modest. If one AAD ‘fails’, a clinically acceptable response may be achieved with another agent. Proarrhythmia or extra-cardiac side effects are frequent. Safety rather than efficacy considerations should guide the choice of AAD. Young patients should be considered for rhythm control Make sure patient has had adequate anticoagulation prior to initiation.
Slide 50-

New algorithm for sinus rhythm maintenance in AF
Slide 51-

Flecainide Drug of choice in pts with structurally normal hearts Start with 50 mg BID and then increase to 100 mg BID Start AV nodal blocking agent concomitantly Treadmill stress test 1 week after initiation Avoid if Cr Cl < 35 Adverse effects: - proarrhythmias - conduction abnormalities - acute rise in pacing threshold - heart failure exacerbation
Slide 52-

Propafenone similar to Flecainide only difference: liver metabolism, so safe to use in renal failure patients 150 mg TID, upto 300 mg TID
Slide 53-

Dofetilide Pure Class III agent Dose 125 – 500 mg BID based on Cr Cl cannot use with Verapamil or HCTZ Proarrhythmia risk 3.3% highest in first 72 hrs Initiate in hospital can be used in CAD and CHF patients
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Sotalol Class III + non specific beta blocker provides good rate control if Afib recurs renal excretion- dose adjustment in CRI 80-160 mg BID preferred in pts with ICD preferred in pts with CAD Do not use in patients with CHF and EF<25% Proarrhythmia risk 2-3% initiate in hospital
Slide 55-

Dronedarone Amiodarone without the iodine moiety Class III agent, multichannel blocker + antiadrenergic activity. ATHENA: Reduction in hospitalization compared to placebo. reduction in cardiovascular deaths ANDROMEDA: stopped prematurely increased mortality in pts with advanced heart failure. PALLAS: increased rates of heart failure, stroke, and death from cardiovascular causes in permanent afib pts who were at risk for major vascular events Dosage: 400 mg BID
Slide 56-

Amiodarone Most effective of the AADs but also most toxic Multi channel blocker Loading: 400 mg PO BID/TID Maintenance: 200 mg daily EKG 1 week after initiation Adverse effects: Bradycardia, liver toxicity, QT prolongation (<0.5%), Hypothyroidism(20%), Hyperthyroidism (3%), Lung toxicity, Skin pigmentation Drug interaction: reduces hepatic metabolism of digoxin and warfarin. Monitoring: LFTs, TFTs, CXR, PFTs( yearly)
Slide 57-

Catheter ablation for AF
Slide 58-

Guidelines Indicated in patients with Symptomatic paroxysmal AF refractory or intolerant to at least 1 antiarrhythmic medication when a rhythm-control strategy is desired (1A) Symptomatic persistent AF refractory or intolerant to at least 1 antiarrhythmic medication. (2A) Recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy. (2A)
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Catheter ablation of AF Radiofrequency Cryoablation
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Primary endpoint ( Death + CVA + Bleeding + Cardiac arrest) Ablation therapy not superior to drugs for CV outcomes at 5 years Significant reductions in death and CV hospitalizations with ablation On treatment analysis ablation demonstrated superior efficacy As this was a single blinded trial there was a high crossover rate. Time to first AF recurrence was greater
Slide 61-

Restoration of sinus rhythm by catheter ablation in pts with CHF led to significant improvements in LVEF (21%) Symptoms Exercise capacity Quality of life.
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Catheter ablation as compared to amiodarone in pts with CHF More successful in maintaining sinus rhythm Reduction in hospitalizations Reduction in mortality.
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AV node ablation
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AV node ablation Guidelines AV nodal ablation with permanent ventricular pacing is reasonable to control heart rate when pharmacological therapy is inadequate and rhythm control is not achievable. (IIA)
Slide 65-

AV node ablation provides highly effective control of ventricular rate patients in whom pharmacological rate control has failed and rhythm control with drugs and/or LA ablation has failed. improves quality of life reduces mortality patients with reduced LV function may require biventricular pacing after atrioventricular node ablation.
Slide 66-

Left atrial appendage occlusion Watchman device only FDA approved percutaneous LAA closure device semi-spherical nitinol frame with a polyethylene terephthalate membrane coating deployed transseptally using a dedicated 14 Fr sheath usually under transesophageal echocardiography and fluoroscopic guidance.
Slide 67-

707 pts with NV Afib randomized to Watchman vs continued warfarin. Primary efficacy endpoint stroke, systemic embolism and CV death 3.0% vs 4.3% WATCHMAN vs Warfarin (noninferior) Primary safety events 5.5% vs 3.6% (more safety events in the Watchman arm)
Slide 68-

Recommendations FDA approved for patients at increased risk of stroke and systemic embolism based upon CHADS2 or CHA2DS2-VASc scores deemed by their physicians to be suitable for warfarin therapy have an appropriate rationale to seek a nonpharmacological alternative to warfarin
Slide 69-

Conclusions Epidemic of atrial fibrillation. Assess stroke risk and anticoagulate appropriate patients. Rate vs rhythm control strategy. Ablation is effective and safe in selected patients. AV node ablation and pacemaker. NOACs are effective and safe. Consider Watchman in patients not suitable for long term anticoagulation.
Slide 70-

Thank you