Current Guideline for AF Treatment

Young Keun On, MD, PhD, FHRS

Samsung Medical Center

Sungkyunkwan University School of Medicine

Case 1

• 59 year-old lady

• Sudden palpitation and breathlessness for 12 hours

• Remote onset 2 months ago

• Palpitation persisted for 1~2 hours

• HTN (-), DM (-)

Echocardiography

• LVEF 67% LVESD/EDD 30/53 mm

• LA 42 mm LAVI 22 ml/m2

• IVSd 10 mm, LVPWd 10 mm

• Normal LV and RV

• Valve : normal

• Great vessel : normal

What treatment strategy would you choose?

1. Rate control strategy

2. Rate control strategy with anticoagulation

3. Rhythm control strategy

4. Rhythm control strategy with anticoagulation

5. Anticoagulation only

Classification

First detected AF

Permanent AF

(irreversible)

Persistent AF

(Not self- terminating)

> 7 days

Paroxysmal AF

(Self- terminating)

≤ 7 days (most <24hr)

Recurrent : two or more episode

Longstanding persistent AF: continuous AF of greater than one-year duration

Diseases associated with AF

• Valvular Heart Disease : Rheumatic mitral disease

• Non-valvular HD : CAD, HTN

• Hyperthyroidism

• Pulmonary thromboembolism

Rhythm control for AF

• Pharmacologic treatment

• DC cardioversion

• RFCA (radiofrequency catheter ablation)

• Maze operation

Vaughan Williams Classification

of Antiarrhythmic Drug Actions

Type IA (block the sodium channel with intermediate recovery time)

Disopyramide, Procainamide, Quinidine

Type IB (block the sodium channel with rapid recovery time)

Lidocaine, Mexiletine

Type IC (block the sodium channel with slow recovery time)

Flecainide, Moricizine, Propafenone

Type II Beta-blockers (e.g., propranolol)

Type III (prolongation of the cardiac action potential)

Amiodarone, Bretylium, Dofetilide, Ibutilide, Sotalol

Type IV

Calcium-channel antagonists (e.g., verapamil and diltiazem)

2014 AHA/ACC/HRS AF guideline

Rhythm Control in AF

After Medication of Propafenone 300 mg bid

Atrial Fibrillation

• The most common cardiac arrhythmia.

• Confers a 5-fold risk of stroke.

• The rate of ischemic stroke among patients with AF

averages 5% per year.

• One of five (20%) of all strokes is attributed to AF.

• The risk of death from AF-related stroke is doubled.

Treatment strategy of AF

• Prevention of thromboembolism

: Antithrombotic therapy

• Rhythm control

• Rate control

Prevention of thromboembolism

in AF patients

Vitamin K

Antagonist

Warfarin

NOAC

Anticoagulant Anti-platelet agents

Aspirin +/- Clopidogrel

Hart RG et al, Ann Intern Med 1999;131:492

Stroke prevention by Warfarin vs Aspirin in AF patients

Stroke prevention 39%

Stroke and ICH by INR in AF patients

Hylek EM et al, N Engl J Med 1996;335:540

INR

CHA2DS2VASc score and stroke rate

Camm AJ, et al. Eur Heart J 2010

Risk factors

• CHF (1)

• HT (1)

• ≥ 75 yrs old (2)

• DM (1)

• Previous stroke, TIA,

Thromboembolism (2)

• Vascular disease (1)

• 65~74 yrs old (1)

• Female (1) 0

2

4

6

8

10

12

14

16

0 1 2 3 4 5 6 7 8 9

Annual stroke rate

Pisters R, et al, Chest 2010

HAS-BLED bleeding risk score

Bleeding risk score

• Hypertension (1)

• Abnormal renal function (1)

• Abnormal liver function (1)

• Stroke (1)

• Bleeding (1)

• Labile INRs (1)

• Elderly > 65 yrs old (1)

• Drugs (1)

• Alcohol (1)

• Hypertension: systolic blood pressure >160 mmHg

• Abnormal kidney function: the presence of chronic dialysis or renal transplantation or serum creatinine ≥200 mol/L.

• Abnormal liver function: chronic hepatic disease (e.g. cirrhosis) or bilirubin >2 x upper limit of normal in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase >3 x upper limit normal).

• Bleeding : previous bleeding history and/or predisposition to bleeding, e.g. bleeding diathesis, anemia, etc.

• Labile INRs : unstable/high INRs or poor time in therapeutic range (e.g. <60%)

• Drugs/alcohol use : concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse

Bleeding risk score

• Elderly > 65 yrs old (1)

• Stroke (1)

• Hypertension (1)

• Abnormal renal function (1)

• Abnormal liver function (1)

• Bleeding (1)

• Labile INRs (1)

• Drugs (1)

• Alcohol (1)

CHA2DS2VASc score vs HAS-BLED score

Stroke risk factors

• ≥ 75 yrs old (2)

• Previous stroke, TIA,

Thromboembolism (2)

• CHF (1)

• HTN (1)

• DM (1)

• Vascular disease (1)

• 65~74 yrs old (1)

• Female (1)

Recommendations

for Prevention of Thromboembolism in AF

AHA/HRS 2014 OAC OAC/aspirin/No Tx No Tx

Case 1 CHA2DS2VASc score : 1 → 0 • Female (1) ; lone AF

HAS-BLED score : 0

What treatment strategy would you choose?

1. Rate control strategy

2. Rate control strategy with anticoagulation

3. Rhythm control strategy

4. Rhythm control strategy with anticoagulation

5. Anticoagulation only

Case 2

• 60 year-old gentleman

• Palpitation with chest discomfort, dizziness

• Drug refractory recurrent paroxysmal to persistent AF

• Medication Hx : propafenone, flecainide, sotalol

• Hypertension (+) with medication for 2 years

Echocardiography

• Normal LV cavity size & systolic function

• Normal LV wall thickness

• No regional wall motion abnormality

• LVEF: 68% LVIDs/LVIDd: 27/48mm

• LA: 40mm LAVI: 25.7ml/m2

• IVSd : 9mm LVPWd: 10mm

• E: 0.89m/s e`: 0.164m/s E/e`: 5.43

• Ao: 27mm DT: 119.0msec

CHA2DS2VASc score : 1 • HTN

HAS-BLED score : 1

• HTN

What treatment strategy would you choose?

1. Rate control strategy

2. Rate control strategy with anticoagulation

3. Rhythm control strategy

4. Rhythm control strategy with anticoagulation

5. Anticoagulation only

Nattel S, et al. Eur Heart J 2014

A conceptual model of atrial fibrillation events

in relationship to underlying substrate.

Both primary disease and AF-induced structural, electrical, and autonomic remodelling

contribute to progression from paroxysmal to persistent AF.

Recommendations for Thromboembolism

Prevention in Cardioversion of AF/AFL

Recommendations COR LOE

With AF or atrial flutter for ≥48 h, or unknown duration,

anticoagulate with warfarin for at least 3 weeks prior to and

4 weeks after cardioversion

I B

Recommendations COR LOE

With AF or atrial flutter for ≥48 h, or unknown duration,

anticoagulate with warfarin for at least 3 weeks prior to and

4 weeks after cardioversion

I B

With AF or atrial flutter for ≥48 h or unknown duration and no

anticoagulation for preceding 3 weeks, it is reasonable to

perform a TEE prior to cardioversion, and then cardiovert if

no LA thrombus is identified, provided anticoagulation is

achieved before TEE and maintained after cardioversion for

at least 4 weeks

IIa B

With AF or atrial flutter ≥48 h, or unknown duration,

anticoagulation with dabigatran, rivaroxaban, or apixaban

is reasonable for ≥3 weeks prior to and 4 weeks after

cardioversion

IIa C

2014 AHA/ACC/HRS AF guideline

Recurrence of Atrial Fibrillation patients

after DC cardioversion

What treatment strategy would you choose?

1. Rate control strategy

2. Rate control strategy with anticoagulation

3. Rhythm control strategy

4. Rhythm control strategy with anticoagulation

5. Anticoagulation only

Recommendations for Rate Control in AF

Recommendations COR LOE

Control ventricular rate using a beta blocker or

nondihydropyridine calcium channel antagonist for

paroxysmal, persistent, or permanent AF

I B

A heart rate control (resting heart rate <80 bpm) strategy is

reasonable for symptomatic management of AF IIa B

AV nodal ablation with permanent ventricular pacing is

reasonable when pharmacological management is

inadequate and rhythm control is not achievable

IIa B

Lenient rate control strategy (resting heart rate <110 bpm)

may be reasonable with asymptomatic patients and LV

systolic function is preserved

IIb B

Radiofrequency Catheter Ablation (RFCA)

Radiofrequency lesion in human ventricular myocardium

Initiation of Atrial Fibrillation by LSPV ectopic

PAC & induction of AF

AF ablation :

to eliminate AF triggers

to modify the susceptible substrates

PV Isolation by Catheter Ablation

Three dimensional map of the LA and PV

Radiofrequency lesions

CT angiography

Indications for catheter ablation of AF

Indications for catheter ablation of AF Class Level

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Paroxysmal : Catheter ablation is recommended

Persistent : Catheter ablation is reasonable

Longstanding Persistent (>12 months) : Catheter ablation may be considered

I

IIa

IIb

A

A

B

Symptomatic AF prior to initiation of antiarrhythmic drug therapy with a Class 1 or 3

antiarrhythmic agent

Paroxysmal : Catheter ablation is reasonable

Persistent : Catheter ablation may be considered

Longstanding Persistent : Catheter ablation may be considered

IIa

IIb

IIb

B

C

C

2014 AHA/ACC/HRS AF guideline

가. 항부정맥 약제 (I or III) 중 1가지 이상을 6주 이상 충분한 용량으로 투여한 이후에도 증상이 조절되지 않는 심방세동,

약제 투여 전, 후 심전도 검사에서 심방세동이 증명된 경우

영구형 (permanent) 심방세동에는 인정하지 않음

나. 항부정맥 약제에 대한 부작용 또는 동결절 기능부전을 동반한 빈맥-서맥 증후군에서와 같이 약제 유지가 불가능한 심방세동으로 심전도에서 확인된 경우

다. 재시술은 이전 시술 후 3개월이 경과된 이후에 실시, 심전도상 심방세동 또는 심방빈맥의 재발이 증명된 경우

Korea Reimbursement criteria for AF catheter ablation

by Health Insurance Review and Assessment Service

심방세동 고주파절제술의 보험급여기준

2014. 6. 1. 보험인정기준

Case 3

• 68 year-old gentleman

• Frequent dizziness with palpitation

• No functional decline

• Hypertension (+), DM (+)

• Medication of HTN and DM

1초

Tachycardia Bradycardia syndrome

CHA2DS2VASc score : 3

• Age 68 yrs

• HTN

• DM

HAS-BLED score : 2

• Age 68 yrs

• HTN

What treatment strategy would you choose?

1. Rate control strategy with anticoagulation

2. Rhythm control strategy

3. Rhythm control strategy with anticoagulation

4. Anticoagulation only

5. Pacemaker

Points to be considered

1. Tachycardia-bradycardia ?

2. Underlying Sick sinus syndrome ?

What treatment strategy would you choose?

1. Rate control strategy with anticoagulation

2. Rhythm control strategy

3. Rhythm control strategy with anticoagulation

4. Anticoagulation only

5. Pacemaker

Case 4

• 65 year-old lady

• No specific symptom

• Detection of AF in ECG during routine health check up

• No functional decline

• Medication of beta blocker

• No underlying heart and other problem

Echocardiography

• LVEF 58% LVESD/EDD 33/51 mm

• LA 58 mm LAVI 45 ml/m2

• IVSd 10 mm, LVPWd 10 mm

• Normal LV and RV

• Valve : normal

• Great vessel : normal

What treatment strategy would you choose?

1. Rate control strategy

2. Rate control strategy with anticoagulation

3. Rhythm control strategy

4. Rhythm control strategy with anticoagulation

5. Anticoagulation only

Case 4 CHA2DS2VASc score : 2 • 65 years old (1)

• Female (1)

HAS-BLED score : 1

• 65 years old (1)

• Not an ideal candidate for AF ablation

: The patient has a more advanced form of AF.

There is little to be gained from a symptom perspective

AF ablation should not be performed for solely “curative”

purposes.

The predominant arrhythmia mechanism shifts from a focal

“trigger” in paroxysmal AF, to a reliance on an abnormal

anatomic substrate capable of arrhythmia self-perpetuation.

What treatment strategy would you choose?

1. Rate control strategy

2. Rate control strategy with anticoagulation

3. Rhythm control strategy

4. Rhythm control strategy with anticoagulation

5. Anticoagulation only

Summary

• The rate of ischemic stroke among patients with AF averages 5% per year.

• CHA2DS2-VASc score recommended to assess stroke risk.

• With prior stroke, TIA, or CHA2DS2-VASc score ≥ 2, oral anticoagulants

recommended. Warfarin or NOAC

• With nonvalvular AF and CHA2DS2-VASc score of 0, it is reasonable to

omit antithrombotic therapy.

• With AF or atrial flutter for ≥48 h, or unknown duration, anticoagulate with

warfarin for at least 3 weeks prior to and 4 weeks after cardioversion.

• Catheter ablation of AF : symptomatic AF refractory or intolerant to

antiarrhythmic medication