20 Lee Atrial Fibrillation.ppt - UCSF CME · valvular heart disease, AF incidence is decreasing. 10 Miyasaka, Y. et al. Circulation 2006;114:119-125 Incidence of Atrial Fibrillation

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October 2017

Byron K. Lee MDProfessor of MedicineDirector of the EP LaboratoryDivision of CardiologyUniversity of California, San Francisco

Disclosures

Research Medtronic

Zoll

Apama

Consulting CardioNet

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Secretary of Defense: Donald Rumsfeld

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Importance

AF is the most common sustained arrhythmia in adults

Affects 4% of everyone over age 60

10% of everyone over age 80

Aging leads to atrial fibrosis which predisposes to AF

2

Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as

principal diagnosis.

2% VF

34% Atrial

Fibrillation

18% Unspecified

6% PSVT

6% PVCs

4%Atrial

Flutter

9% SSS

8%Conduction

Disease

3% SCD

10% VT

Hospitalization for Arrhythmias (USA)

Bialy D et al. JACC. 1992;19:41A

Cardiologists know what their talking about when it comes to AF.

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THE TOWER OF BABEL

Lone vs Secondary AF Lone AF

Generally young age (<60), without clinical or echocardiographic evidence of cardiopulmonary disease, including HTN

Secondary AF Occurs in the setting of some other illness: ○ MI, cardiac surgery, pericariditis, hyperthyroidism,

PE, pneumonia, etc.

3

Classification of Atrial Fibrillation

Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE. 1992;20:1603-1605

With better treatment of HTN and valvular heart disease, AF incidence is decreasing.

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Miyasaka, Y. et al. Circulation 2006;114:119-125

Incidence of Atrial Fibrillation in different age groups


Overall and sex-specific trends in age-adjusted incidence of AF between 1980 and 2000 (age

adjustment to the 1990 US population)

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Projected Prevalence of Atrial Fibrillation in United States between 2000 and 2050

Obesity and Sleep Apnea are Risk Factors for AF

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Asians have a higher rate of AF than whites.

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Adjusted association between race and medical diagnoses.

Thomas A. Dewland et al. Circulation. 2013;128:2470-2477

Copyright © American Heart Association, Inc. All rights reserved.

5

Except for stroke, AF is a benign disease

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Consequences of Atrial Fibrillation

5- fold in stroke risk

LV function, exercise tolerance, and QOL

Tachycardia-mediated cardiomyopathy

2- fold in cardiac mortality

AF and Dementia

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Bunch TJ et al. Heart Rhythm 2010

Based on the AFFIRM study, rate control and anticoagulation is just as good as rhythm control with antiarrhythmics.

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6

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med 2002;347:1825-1833.

Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group. AF Symptoms

Feeling overtired or a lack of energy (most common)

Pulse that is faster than normal or changing between fast and slow and feels irregular

Shortness of breath

Heart palpitations (feeling like your heart is racing, pounding, or fluttering)

Trouble with everyday exercises or activities

Pain, pressure, tightness, or discomfort in your chest

Dizziness, lightheadedness, or fainting

Increased urination (using the bathroom more often)

1. http://www.hrsonline.org/Patient-Resources/Heart-Diseases-Disorders/Atrial-Fibrillation-

CHADS2 is an outdated approach to determine which patients need anticoagulation

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Anticoagulation in AF: Who needs it?

CHADS 2 score:1

1 point for:CHF (or reduced systolic function), HTN, age ≥ 75 years, DM

2 points for:History of stroke or TIA

0: very low risk 1: low risk

2-3: moderate risk4-6: high risk

1. JAMA 2001;285:2864-2870

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Adapted from Olesen JB. BMJ 2011;342:d124

CHA2DS2-VASc score

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CHA2DS2-VASc scoreCHA2DS2-VASc Improves Risk Stratification of

AF Patients With a CHADS2 Score of 0–1

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1 Year Follow-up

Person-years Events Stroke Rate (95% CI)

CHADS2 score=0 17,327 275 1.59 (1.41-1.79)

CHA2DS2-VASc=0 6919 58 0.84 (0.65-1.08)

CHA2DS2-VASc=1 6811 119 1.75 (1.46-2.09)

CHA2DS2-VASc=2 3347 90 2.69 (2.19-3.31)

CHA2DS2-VASc=3 250 8 3.20 (1.60-6.40)

CHADS2 score=1 22,945 1130 4.92 (4.65-5.22)

CHA2DS2-VASc=1 2069 40 1.93 (1.42-2.64)

CHA2DS2-VASc=2 8516 345 4.05 (3.65-4.50)

CHA2DS2-VASc=3 11,223 652 5.81 (5.38-6.27)

CHA2DS2-VASc=4 1137 93 8.18 (6.68-10.02)

Olesen JB.Tromb Haemost 2012;107:1172-1179

8

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Lip et al. Journal of Internal Medicine 201530

Lip et al. Journal of Internal Medicine 2015

Amiodarone is a dangerous drug and it should be not be used first line to prevent AF.

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AF Guidelines 2011

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Ablation can cure AF.

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Focal Atrial Fibrillation

Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins

Michel Haïssaguerre, M.D., Pierre Jaïs, M.D., Dipen C. Shah, M.D., Atsushi Takahashi, M.D., Mélèze Hocini, M.D., Gilles Quiniou, M.D., Stéphane Garrigue, M.D., Alain Le Mouroux, M.D.,

Philippe Le Métayer, M.D., and Jacques Clémenty, M.D.

1998

Anatomic PV Isolation

Pappone, et al. JACC 2003

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Cryoballoon (Arctic Front)

• Paroxysmal AF (STOP AF 69% success at 1 year

compared to drugs 7%)

• PV stenosis, phrenic nerve palsy (6%)

• Decreased risk of esophageal injury

Website of a Bay Area Hospital

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“Treating Atrial fibrillation (AF) with ablation or pulmonary vein antral isolation, results in a complete cure from atrial fibrillation in more than 90% of patients.”

Long Term Success After 1 Ablation

39Ouyang et al. Circulation 2010

Long Term Success After 1-3 ablations

40Ouyang et al. Circulation 2010

11

Cappato et al. Circ Arrhythm Electrophysiol. 2010

Success Based on Type of Atrial Fibrillation

Complications CVA, TIA, air embolism Left sided atrial arrhythmias Pulmonary vein stenosis AV fistulae, femoral pseudoaneurysm Coronary artery occlusion Death (1/1000) Mechanical

Perforation○ During transseptal puncture- aorta, LA○ During ablation- LA appendage○ Atrio Esophageal Fistula

Phrenic nerve paralysis Valve damage

Who is a candidate for AF Catheter Ablation?

Paroxysmal Symptomatic

Failed antiarrhythmics or young and want to avoid meds

Persistent and Permanent Highly symptomatic

Poor hemodynamics

Tachycardia induced cardiomyopathy

Failed antiarrhythmics

If you fail PV isolation you will have to live with the symptoms of AF.

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12

(b)

(c)

(d)

(e)(f)

1

(a)

Method #1

HOW TO STOP A RUNAWAY STAGE

2Method #2

(b)

(c)

(d)

(e)(f)

(a)

1

(a)

Method #1

HOW TO STOP A RUNAWAY STAGE

Complete AV Node Ablation Complete AV Node AblationPM

13

Complete AV Node Ablation

Yeung-Lai-Wah, 1991

Trohman, 1992

Olgin, 1993 54

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32

9.7±4.7

24±8

87.3% 12±6

98%

98%

AUTHOR Pt No. LONG-TERMSUCCESS

F/U (months)

SYMPTIMPROV

97%

100%

84%

Jensen, 1995 50 1794% 88%

Surgical AF Ablation (MAZE) Procedure

Wolf et al. J Thorac Cardiovasc Surg.2005;130:797-802.

Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation

If you have a CHADS2VASc of 6+ and recurrent bleeding on anticoagulation, you’re out of luck.

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Watchman Device to occlude Left Atrial Appendage

Holmes et al. PROTECT AF. Lancet 2009

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PROTECT AF STUDYProvided Proof of Principle

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

DEVICE CONTROL

2.4%

1.6%

0.2%

1.9%

2.6%

3.5%

ISCHEMIC

HEMORRHAGIC

ALL

Device is non‐inferiorto warfarin in stroke

May provide analternative to warfarin

Conclusions:STROKE RATES(95% CI)

Thrombus after Watchman Implant

54Patel et al. Cardiol Resid Pract 2012

Percutaneous Epicardial Left Atrial Appendage Ligation

Bartus, et al. JACC 2013;62:108-18.

76 year old Caucasian man presents for routine device check

PMH: SSS, s/p DDD pacemaker, HTN, CAD

Pacer interrogation: 3 AF episodes – lasting 5, 15 and 90 minutes. Ventricular rate up to 130 bpm. Mean VR in AF 88 bpm.

Asymptomatic: Does not recall the episodes of AF

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QuestionAsymptomatic AF on Cardiac Device lasting 90 minutes : a) Do nothing

b) Start ASA

c) Anticoagulate with warfarin or NOAC

TRENDS TrialAF Burden & Thromboembolic Events

Annualized Rate

(Stroke & TIA)

Annualized Rate

(Stroke only)

Zero burden 1.1% 0.5%

Low burden < 5.5 hours

1.1% 1.1%

High burden ≥ 5.5 hours

2.4% 1.8%

Glotzer TV, et al. Circ Arrhythm Electrophysiol. 2009;474-480.

ASSERT TrialStroke or Systemic Embolism

Healy JS, et al. N Engl J Med. 2012;366:120-129.

Device-Detected Atrial Tachyarrhythmia > 6minDetected 0-3 months

No Atrial TachycardiaDetected 0-3 months

HR = 2.4995% CI, 1.28-4.85P = 0.007

# at Risk Year 0.5 1.0 1.5 2.0 2.5+ 261 249 238 218 178 122- 2,319 2,145 2,070 1,922 1,556 1,197

Years of Follow-upT0 at 3-month visit

Cum

ulat

ive

Haz

ard

Rat

es

0 0.5 1.0 1.5 2.0 2.5

0.0

0.02

0.04

0.06

0.08

0.10

0.69%/yr

1.61%/yr

QuestionAsymptomatic AF on Cardiac Device lasting 90 minutes: a) Do nothing

b) Increase to aspirin 325mg daily

c) Anticoagulate with warfarin or NOAC

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90 year old frail Asian woman is found to have new onset AF Presentation: New palpitations and found on ECG

to have AF at 85 bpm

PMH: HTN, DM

Meds: Toprol XL

Echo: LVH, Sclerotic AV, EF 66%

a) Start aspirin 81 mg daily

b) Start aspirin 325mg daily

c) Adjusted dose warfarin INR 2-3

d) Start NOAC

90 year old frail Asian woman found to have new onset AF

Date of download: 4/14/2015

From: Warfarin Use among Ambulatory Patients with Nonvalvular Atrial Fibrillation: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

Ann Intern Med. 1999;131(12):927-934. doi:10.7326/0003-4819-131-12-199912210-00004

Prevalent warfarin use by age among 11 082 ambulatory patients with nonvalvular atrial fibrillation and no identified contraindications to warfarin therapy.Numbers in parentheses represent the number of patients in the denominator of each category. Error bars represent upper 95% confidence limits.

Figure Legend:

Copyright © American College of Physicians. All rights reserved.64

ATRIA Study Data Singer et al. Annals of Internal Medicine 2009

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c) Adjusted dose warfarin INR 2-3

d) Start NOAC

90 year old frail Asian woman found to have new onset AF

Apixiban

88 year old frail Black woman found to have new onset AF PMH: HTN, GERD

Meds: Metoprolol XL 25mg daily, lisinopril 10mg daily, ASA 81mg daily

Upon further questioning you find out that she has mild Parkinson’s disease with 4 mechanical falls over the past year. No head injury

No LOC.



c) Start aspirin and plavix

d) Start warfarin or NOAC

88 year old frail Black woman found to have new onset AF and frequent falls

Estimated that a patient had to fall 295x per year for the risk of intracranial hemorrhage to outweigh the benefit of warfarin!

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c) Start aspirin and plavix

d) Start warfarin or NOAC

88 year old frail Black woman found to have new onset AF and frequent falls

Summary: AF Truths Cardiologists do not always know what their talking

about when it comes to AF.

Despite better treatment of HTN and valvular heart disease, AF incidence is still increasing.

AF is not a benign disease. It causes stroke, decreased EF, adverse symptoms, and possibly dementia.

Based on the AFFIRM study, rate control and anticoagulation is just as good as rhythm control with antiarrhythmics only for asymptomatic or minimally symptomatic patients.

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Summary: AF Truths CHADS2 should be replaced by CHADS2VASc to

determine which patients need anticoagulation

Amiodarone is a potentially dangerous drug and but should be used first line to prevent AF in patients with LVH.

Ablation cannot cure AF.

If you fail PV isolation you do not have to live with the symptoms of AF.

For patients who bleed on AC, LA appendage closure is an option.

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Summary: AF Truths AC for high CHADS2VASc patients even if AF is

asymptomatic and discovered by an implantable device

Elderly patients are more likely to benefit from AC for AF

Patients need to fall 295x per year before the risk of intracranial bleeds outweigh the benefit of AC to prevent ischemic stroke.

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UCSF Cardiac Electrophysiology

Dr. Nitish Badhwar

Dr. Edward Gerstenfeld

Dr. Henry Hsia

Dr. Byron Lee

Dr. Randy Lee

Dr. Gregory Marcus

Dr. Joshua Moss

Dr. Jeffrey Olgin

Dr. Melvin Scheinman

Dr. Zian Tseng

Dr. Vasanth Vendantham

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MD Referral Coordinator:Ms. Deanna Galvan415-476-8237

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Hope I did Not Lose You

Laser Balloon Ablation

Compliant Balloon

Visualization of PV to avoid stenosis

Avoid use of Imaging of LA

Phrenic nerve palsy

AF Burden and Risk of StrokeAF Burden value Hazard Ratio 95% Confidence

IntervalP value

< 5 vs. > 5 min 1.76 1.02‐3.02 p=0.041

< 1 vs. > 1 hr 2.11 1.22 to 3.64 p=0.008

< 6 vs. > 6 hr 1.74 0.96 to 3.41 p=0.067

< 12 vs. > 12 hr 1.72 0.92 to 3.22 p=0.090

< 23 vs. > 23 hr 1.44 0.69 to 3.01 p=0.332

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Atrial fibrillation

Valvular AF*

VKA

Yes

No antithrombotic therapy

Yes

0

* Includes rheumatic valvular AF, hypertrophic cardiomyopathy, etc.

** Antiplatelet therapy with aspirin plus clopidogrel, or – less effectively – aspirin only, may be considered in patients who refuse any OAC.

Colour: CHA2DS2‐VASc score; green = 1, blue = 2, red = ≤2. Line: Solid: best option; Dashed: alternative option. If absolute contraindications to any OAC or anti‐platelet therapy, left atrial appendage closure device can be considered.AF = atrial fibrillation; CHA2DS2‐VASc = see text; HAS‐BLED = see text; NOAC = novel anticoagulants; VKA = vitamin K antagonist.

1** ≥2

NOAC

Oral anticoagulant therapy

Assess bleeding risk (HAS‐BLED score)Consider patient values and preferences

No (i.e. non‐valvular AF)

Assess risk of stroke (CHA2DS2‐VASc score)

No

< 65 years and lone AF (including females)

Choice of Anticoagulant

Eur Heart J 2012;33:2719‐2747

Pulmonary Vein Isolation

Lasso Catheter

Ablation Catheter

51 yo fireman presents with newly diagnosed asymptomatic persistent AF. With CHADS2 and CHADS2VASc of zero, we can externally cardiovert and put him on ASA 325 mg daily.

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External CV

• Most thrombi in atrial fibrillation arise from the left atrial appendage

• Cardioversion can reduce left atrial appendage function

-- Even after conversion from AF to sinus

• The pericardioversion is a particularly pro-thrombotic time

-- Regardless of mode: DC/ electrical, pharmacologic, spontaneous

• During and after cardioversion:1, 2

-- Anticoagulation for at least 4 weeks

-- Applies even to those who would otherwise not require anticoagulation 1. JACC 2006;48:e149-246

2. Chest 2004;126:429S-456

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Final Word on Nutritional Studies

It's a relief to know the truth after all those conflicting reports.

1. The Japanese eat very little fatand suffer fewer heart attacks than Americans.

2. The Mexicans eat a lot of fatand suffer fewer heart attacks than Americans.

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3. The Chinese drink very little red wineand suffer fewer heart attacks than Americans.

4. The Italians drink a lot of red wineand suffer fewer heart attacks than Americans.

5. The Germans drink a lot of beers and eat lots of sausages and fats and suffer fewer heart attacks than Americans.

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1. Eat and drink what you like.

2. Speaking English is apparently what kills you.

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Conclusions:

SECTION HEADING

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Documents

20 Lee Atrial Fibrillation.ppt - UCSF CME · valvular heart disease, AF incidence is decreasing. 10 Miyasaka, Y. et al. Circulation 2006;114:119-125 Incidence of Atrial Fibrillation