You are on page 1of 70

AF……..

an update
Dr. Barun Kumar
28.01.11
Classification of Atrial Fibrillation
ACC/AHA/ESC Guidelines
First
Detected

Paroxysmal Persistent
(Self-terminating) (Not self-terminating)

Permanent
DIAGNOSTIC WORKUP
Identify Causes and Risk Factors
• Minimum Evaluation
• History and physical – BP, CV dz
• Electrocardiogram – WPW, LVH, MI
• Echocardiogram – LVH, LAE, EF, Valve Dz
• Labs – TSH, Renal fxn, LFTs (Clearance,ETOH)
[D-dimer, ESR]
• Additional Testing
• ETT – CAD, Exercise induced SVT / AF
• Holter / Event Monitor – Confirm AF and Sxs
• TEE – LA clot [CXR]
• EPS – SVT triggered AF
AHA / ACC / ECS Guidelines 2006
Goals of Therapy
1. Relieve symptoms

2. Prevent Stroke

3. Prevent Heart Failure


AF: TREATMENT OPTIONS
Rate control Maintenance of SR Stroke prevention

Pharmacologic Nonpharmacologic Pharmacologic


Pharmacologic • Warfarin
• Ca2+ blockers • Thrombin inhibitor
∀ β -blockers • Heparin
• Digitalis • Aspirin
• Amiodarone Class IA Catheter ablation
Class IC Surgery (MAZE) Nonpharmacologic
Nonpharmacologic Class III Pacing • Removal / isolation
• Ablate and pace β -blocker LA appendage

Prevent remodeling ACE-


I
ARB

Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.


Risk Factors for Thromboembolism in AF
High-Risk Factors Recommended Therapy
Previous CVA / TIA / Embolism High-risk factor or > 2
Mitral Stenosis moderate-risk factors
Prosthetic heart valve Coumadin INR 2-3
Moderate-Risk Factors(mechanical valve INR > 2.5)
Age > 75 yrs
HTN 1 moderate-risk factor
CHF ASA or Coumadin
DM
EF < 35% No risk factors
Weaker-Risk Factors ASA 81-325mg daily
Female
CAD
Thyrotoxicosis
Age 65 – 74 yrs

AHA / ACC / ECS Guidelines 2006


D-Dimer Prediction of Risk
Evaluate whether elevated D-dimer levels can predict thromboembolic and cardiovascular
events in patients with atrial fibrillation during oral anticoagulant therapy.

Single-center, prospective, study of 269 pts with atrial fibrillation treated with warfarin

D-dimer levels were measured

End points were thromboembolic events and combined cardiovascular events (thromboembolic
events, cerebral hemorrhage, myocardial infarction, cardiovascular death).

RESULTS:
D-dimer levels were elevated (> or =0.5 microg/ml) in 63 (23%) patients.

During an average follow-up period of 756 +/- 221 days:


1. 10 (1.8%/year) thromboembolic events (8 ischemic strokes, 1 transient ischemic attack,
and 1 peripheral embolism
2. 27 (4.8%/year) combined cardiovascular events (10 thromboembolisms, 9 deaths from
heart failure, 3 sudden deaths, 2 myocardial infarctions, and 3 cerebral hemorrhages)

Patients with elevated D-dimer levels experienced higher thromboembolic and combined
cardiovascular events.

Sadanaga T, et. AL; J Am Coll Cardiol. 2010 May 18;55(20):2225-3.


Dabigatran vs. Warfarin
Noninferiority trial randomly assigned 18,113 patients who had atrial fibrillation and a risk of stroke to receive:
1. Fixed doses of dabigatran — 110 mg or 150 mg twice daily in a blinded fashion
2. Adjusted-dose warfarin in an unblinded fashion

The median duration of the follow-up period was 2.0 years.


The primary outcome was stroke or systemic embolism.

Results

Primary outcome
1.69% per year in the warfarin group
1.53% per year in the group that received 110 mg of dabigatran (P<0.001 for noninferiority)
1.11% per year in the group that received 150 mg of dabigatran ( P<0.001 for superiority)
Major bleeding
3.36% per year in the warfarin group
2.71% per year in the group receiving 110 mg of dabigatran (P=0.003)
3.11% per year in the group receiving 150 mg of dabigatran (P=0.31).
Hemorrhagic stroke
0.38% per year in the warfarin group
0.12% per year with 110 mg of dabigatran (P<0.001)
0.10% per year with 150 mg of dabigatran (P<0.001).
Mortality rate
4.13% per year in the warfarin group
3.75% per year with 110 mg of dabigatran (P=0.13)
3.64% per year with 150 mg of dabigatran (P=0.051).
Conclusions
Dabigatran 110 mg had rates of stroke and systemic embolism similar to warfarin with less major hemorrhage.
Dabigatran 150 mg had lower rates of stroke and systemic embolism but similar rates of major hemorrhage.

Stuart J. Connolly and the RE-LY Steering Committee and Investigators NEJM Sept 17, 2009, No. 12, Vol 361: 1139-1151
AF THERAPY

ANTITHROMBOTIC RX
AND

RHYTHM OR ? RATE
CONTROL CONTROL
AFFIRM Trial: Rate vs Rhythm Control
Management Strategy Trial
• Design
– 5-year, randomized, parallel-group study comparing
rate control vs. AARx attempt at NSR
– Primary endpoint: overall mortality
• Patient population
– 4060 patients with AF and risk factors for stroke
– Minimal symptoms
– Mean Age = 69 yr
– Hx of hypertension: 70.8%
– CAD: 38.2%
– Enlarged LA: 64.7%
– Depressed EF: 26.0%

The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833.


AFFIRM: All-Cause Mortality
30
Rate
25 Rhythm

20
Mortality, %

p=0.078 unadjusted
15
p=0.068 adjusted
10

0 1 2 3 4 5
Time (years)
Rhythm N: 2033 1932 1807 1316 780 255
Rate N: 2027 1925 1825 1328 774 236

The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833.


AFFIRM: Adverse Events
Rate Rhythm
Ischemic stroke 77 (5.5%)* 80 (7.1%)*

INR < 2.0 27 (35%) 17 (21%)

Not taking warfarin 25 (32%) 44 (55%)

* p=0.79

The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833.


Atrial fibrillation: Why Control Rate?
Rate control – the problem:

Increased rates – more symptomatic, greater hemodynamic impact.

Persistent increased rates – tachycardia induced cardiomyopathy

Rate control – the goal:

PAF – control symptomatic tachycardia

Chronic afib – mean 24hr HR < 80-90 bpm (?)


RACE II
• Hypothesis: Lenient rate control is not inferior to strict rate control for preventing
cardiovascular morbidity and mortality in pts with permanent AFib

• Randomly assigned 614 patients with permanent AF to:


– lenient rate-control strategy (resting heart rate <110 beats per minute)
– strict rate-control strategy (resting heart rate <80 beats per minute and heart rate during
moderate exercise <110 beats per minute).
• Primary outcome was a composite of death from cardiovascular causes,
hospitalization for heart failure, and stroke, systemic embolism, bleeding, and life-
threatening arrhythmic events.
• The duration of follow-up was at least 2 years, with a maximum of 3 years.
• Results:
• Primary outcome at 3 years was 12.9% in the lenient-control group and 14.9% in the
strict-control group. (90% confidence interval, –7.6 to 3.5; P<0.001 for the
prespecified noninferiority margin).
• The frequencies of the components of the primary outcome were similar in the two
groups. More patients in the lenient-control group met the heart-rate target or targets
97.7% vs. 67.0% in the strict-control group; P<0.001 with fewer total visits (75 vs.
684]; P<0.001). The frequencies of symptoms and adverse events were similar in the
two groups.
• Conclusions: In patients with permanent atrial fibrillation, lenient rate control is as
effective as strict rate control and is easier to achieve.

Van Gelder, et.al, for the RACE II Investigators NEJM April 15, 2010, No. 15, Vol 362: 1363-1373
Atrial fibrillation
Rate control – Drug Therapy:
Digoxin – controls resting rate, OK in CHF patients .

Beta, Ca+2 blockers – controls resting and exercise rates.

Best therapy – combination of beta blocker and


digoxin.

Even in the best of circumstances pacing support is sometimes


required

Goal: Chronic afib – mean 24hr HR < 80-90 bpm (?)


APPROACHES TO AF THERAPY
Rate control plus
anticoagulation preferred
• No or lesser AF symptoms
• Longer AF Hx
• More SHD
• Toxicity Risk Rhythm control
• Elderly preferred
• Greater risk of
proarrhythmia • 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


Atrial Fibrillation Length of time
in AF prior to
cardioversion
100 < 3 Months
3 - 12 Months
> 12 Months

Patients in sinus rhythm (%)


80
Duration of
AF is the best 60
predictor of
recurrent AF 40
after *
cardioversion 20

0
*P = <0.02 Initial One month Six months
post-CV post-CV
Dittrich HC. Am J Cardiol. 1989;63:193-197.
Rhythm Control for AF: Commonly
Used Oral Antiarrhythmic Drugs
Class IA Class IC Class III

Quinidine Propafenone Sotalol

Procainamide Propafenone SR Amiodarone

Disopyramide Flecainide Dofetilide

Procainamide, disopyramide, and amiodarone are not FDA-approved for


treatment of AF.

Miller and Zipes. In: Braunwald, et al (eds). Heart Disease. 6th ed. 2001.
AF Efficacy:
Maintaining NSR > 6 Months
70

60

50
NSR, %

40

30

20

10

0
No Quin Diso Prop Flec Sot Dof Azim Amio
drug
Prevention of atrial fibrillation by Renin-
Angiotensin system inhibition
Meta analysis of published clinical trial data on the effects of renin-angiotensin system (RAS)
inhibition for the prevention of atrial fibrillation

A total of 23 randomized controlled trials with 87,048 patients were analyzed.

In primary prevention: 6 trials in hypertension, 2 trials in myocardial infarction, and 3 trials in


heart failure were included.

In secondary prevention: 8 trials after cardioversion and 4 trials assessing the


medical prevention of recurrence were included.

Overall, RAS inhibition reduced the odds ratio for AF by 33% (p < 0.00001), but there was
substantial heterogeneity among trials.

In primary prevention:
RAS inhibition was effective in patients with heart failure and those with hypertension and
left ventricular hypertrophy but not in post-myocardial infarction patients overall.
In secondary prevention:
RAS inhibition was often administered in addition to antiarrhythmic drugs, including
amiodarone, further reducing the odds for AF recurrence after cardioversion by 45% (p =
0.01) and in patients on medical therapy by 63% (p <0.00001).

RAS inhibition is an emerging treatment for the primary and secondary prevention of AF

Schneider MP, et. Al. J Am Coll Cardiol. 2010 May 25;55(21):2299-307


Atrial Fibrillation Guidelines
Update

Introduction
Anne M Gillis MD, FRCPC, FHRS
Professor of Medicine
Department of Cardiac Sciences
University of Calgary
Leadership. Knowledge. Community.
Libin Cardiovascular Institute of
T he GRADE A ppr oach
Clear separation of 2 issues:

1. Four Categories of Quality of Evidence:


 High, Moderate, Low or Very Low

2. Strength of Recommendations : 2 Grades


 Strong or Conditional (weak)
 Quality of evidence only one factor

31 *www.GradeWorkingGroup.org Leadership. Knowledge. Community.


Recommendations
 1. We recommend that all patients with AF or AFL
(paroxysmal, persistent or permanent), should be
stratified using a predictive index for stroke (e.g.
CHADS2) and for the risk of bleeding (e.g. HAS-BLED),
and that most patients should receive antithrombotic
therapy. (Strong recommendation, High Quality
Evidence)

32 Leadership. Knowledge. Community.


33 Leadership. Knowledge. Community.
Bleeding Risk – HAS-BLED Score

www.escardio.or
g
RRR = 64%
35 Leadership. Knowledge. Community.
Hart Ann Int Med 1999;131:492
RRR = 19%
36 Leadership. Knowledge. Community.
Hart Ann Int Med 1999;131:492
Recommendations - Antithrombotic

 2. We recommend that patients at very low risk of


stroke (CHADS2 = 0) should receive aspirin (75-
325 mg/day). (Strong recommendation, High Quality
Evidence). We suggest that some young persons with
no standard risk factors for stroke may not require ay
antithrombotic therapy. (Conditional recommendation,
Moderate Quality Evidence).

37 Leadership. Knowledge. Community.


Recommendations - Antithrombotic

 3. We recommend that patients at low risk of stroke (CHADS2


= 1) should receive OAC therapy (either warfarin [INR 2 – 3] or
dabigatran). (Strong recommendation, High Quality Evidence).
We suggest, based on individual risk/benefit considerations,
that aspirin is a reasonable alternative for some. (Conditional
recommendation, Moderate Quality Evidence).

 4. We recommend that patients at moderate risk of stroke


(CHADS2 ≥ 2) should receive OAC therapy (either warfarin
[INR 2 – 3] or dabigatran). (Strong recommendation, High
Quality Evidence)

38 Leadership. Knowledge. Community.


RCTs of Adjusted Dose Warfarin vs. Aspirin
Hart. Ann Int Med 2007;147:590

RRR=39%
39 50%Leadership.
0 Knowledge.
-50%Community.
Warfarin Better Warfarin Worse
40
40
35
17 24
30 28
Events/1000 patients/year

25
No antithr
20 13 18
19 Warfarin
15 Aspirin
10 10 12

5
0
CHADS
7 011 CHADS 1 CHADS 2
10 17 14 23

Risk of Stroke + Non-cerebral Major Bleed among AF Patients


Recommendations - Antithrombotic
 5. We suggest, that when OAC therapy is indicated,
most patients should receive dabigatran in
preference to warfarin. In general, the dose of
dabigatran 150 mg po bid is preferable to a dose
of 110 mg po (exceptions discussed in text).
(Conditional recommendation. High Quality Evidence).

41 Leadership. Knowledge. Community.


Connolly SJ, et al. NEJM 2009;361

RR = 0.91, P<0.001, non-inf

RR = 0.66, P<0.001 sup

mo.

RE-LY Trial. Stroke or Systemic Embolism


Major bleeding rates
RR 0.80 (95% CI: 0.69–0.93)
p=0.003 (sup) RR 0.93 (95% CI: 0.81–1.07)
3.50
p=0.31 (sup)
3.36
RRR
3.00 3.11
20%
2.50 2.71

2.00

1.50

1.00
r aey r e p %

0.50

0.00
D110 mg BID D150 mg BID Warfarin

322 / 6,015 375 / 6,076 397 / 6,022


Connolly SJ., et al. NEJM published online on Aug 30th 2009. Dabigatran etexilate is in clinical development and not licensed for
DOI 10.1056/NEJMoa0905561 clinical use in stroke prevention for patients with atrial fibrillation
Recommendations - Cardioversion
6. We recommend that hemodynamically stable patients with
AF or AFL of ≥ 48 hr or uncertain duration for whom
electrical or pharmacological cardioversion is planned should
receive therapeutic OAC therapy (warfarin [INR 2-3] or dabigatran)
for 3 weeks before and at least 4 weeks post cardioversion.

Following attempted cardioversion:


 If AF or AFL persists or recurs or if symptoms suggest that the presenting AF or
AFL has been recurrent, the patient should have antithrombotic therapy
continued indefinitely using either OAC or aspirin as appropriate.

 If sinus rhythm is achieved and sustained for 4 weeks, the need for ongoing
antithrombotic therapy should be based upon the risk of stroke and, in
selected cases, expert consultation may be required.

(Strong recommendation, Moderate Quality Evidence)

44 Leadership. Knowledge. Community.


Recommendations - Cardioversion
7. We recommend that hemodynamically stable patients with AF or AFL of
known duration < 48 hr may undergo cardioversion without prior or
subsequent anticoagulation. However, if the patient is at particularly high risk
of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke or TIA),
cardioversion should be delayed and the patient should receive OAC for 3
weeks before and at least 4 weeks post cardioversion.

Following attempted cardioversion:


 If AF or AFL persists, recurs, or if symptoms suggest that the presenting AF or AFL
has been recurrent, antithrombotic therapy (OAC or aspirin as appropriate) should be
commenced and continued indefinitely.

 If NSR is achieved and sustained for 4 weeks, the need for ongoing antithrombotic
therapy should be based on the risk of stroke according to CHADS2 score and, in
selected cases, expert consultation may be required.

45 Leadership. Knowledge. Community.


(Strong recommendation, Low Quality Evidence)
Recommendations - Cardioversion
 8. We suggest that hemodynamically unstable patients with AF or
AFL who require emergency cardioversion be managed as follows:

a) If the AF or AFL is of known duration < 48 hr, the patient may generally undergo
cardioversion without prior anticoagulation. However, if the patient is at particularly high risk
of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke or TIA), the patient
should receive IV UFH or LMWH before cardioversion is possible, or immediately thereafter
if even a brief delay is unacceptable, and then be converted to OAC for at least 4 weeks
post cardioversion.

b) If the AF or AFL is of ≥ 48 hr or uncertain duration, we suggest the patient receive IV


UFH or LMWH before cardioversion if possible, or immediately therafter if even a brief
delay is unacceptable. Such a patient should then be converted to OAC for at least 4
weeks post cardioversion.

Following attempted cardioversion, the guidelines for subsequent antithrombotic


therapy are identical to those for the management of hemodynamically stable
patients undergoing cardioversion.

(Conditional recommendation, Low Quality Evidence)


46 Leadership. Knowledge. Community.
Recommendations - Cardioversion
 9. We suggest that hemodynamically stable
patients with AF or AFL of duration ≥ 48 hr or
unknown, may undergo cardioversion guided by TEE,
following the protocol from the ACUTE trial.
(Conditional recommendation, High Quality Evidence)

A high quality RCT of conventional OAC strtegy vs. OAC


guided by TEE, and the recommendations of prior
consensus groups (ACCP, AHA/ACC, ESC)

47 Leadership. Knowledge. Community.


Recommendations – Stable CAD
 10. We suggest that patients with AF or AFL who have stable
CAD should receive antithrombotic therapy selected based
upon their risk of stroke (aspirin for CHADS2 = 0 and OAC for
CHADS2 ≥ 1). Warfarin is preferred over dabigatran for those
at high risk of coronary events.
(Conditional Recommendation, Moderate Quality Evidence)

RCTs of aspirin and warfarin showing similar risk reductions for


primary prevention and for stable CAD. No studies of dabigatran
for prevention of coronary events. RCT showing increased risk of
MI with dabigatran vs. warfarin.

48 Leadership. Knowledge. Community.


Recommendations – ACS and/or PCI
 11. We suggest that patients with AF or AFL who have
experienced ACS or who have undergone PCI, should
receive antithrombotic therapy selected based on a
balanced assessment of their risks of stroke, of
recurrent coronary artery events and of hemorrhage
associated with the use of combinations of antithrombotic
therapies, which in patients at higher risk of stroke may
include aspirin plus clopidogrel plus warfarin. (Conditional
Recommendation, Low Quality Evidence).

49 Leadership. Knowledge. Community.


Recommendations – ACS and/or PCI
RCTs showing incremental benefit of clopidogrel + aspirin
post ACS and post PCI for up to 1 year. In ACS, no trials of
warfarin vs clopidogrel + aspirin. In PCI, RCTs show warfarin
inferior to clopidogrel + aspirin.
RCTs showing required duration of clopidogrel + aspirin for
BMS < DES.
Case series showing wide range of bleeding risks with
«Triple therapy» post ACS/PCI, but likely increase over
clopidogrel + aspirin.
Recommendations from consensus groups are evolving.

50 Leadership. Knowledge. Community.


Recommendations –
Surgical/Diagnostic Procedures
 12. We suggest that patients with AF or AFL who are
receiving aspirin, clopidogrel, or OAC and are
scheduled for a surgical or diagnostic procedure
carrying a risk of major bleeding be stratified by their risk of
stroke:
a) If there is a very low to moderate risk of stroke
(CHADS2 ≤ 2), the patient should have their antithrombotic
agent discontinued before the procedure (aspirin or
clopidogrel for 7-10 days, warfarin for 5 days if the INR was
in the range 2- 3, and dabigatran for 2 days). Once post
procedure hemostasis is established (about 24 hr) the
antithrombotic therapy should be reinstated.
(Conditional Recommendation, Low Quality Evidence)

51 Leadership. Knowledge. Community.


Recommendations –
Surgical/Diagnostic Procedures
• b) If there is a par ticular ly high risk of stroke (e.g. prosthetic valve,
recent stroke or TIA, rheumatic valve disease, CHADS2 ≥ 3) or of other
thromboembolism (e.g. Fontan procedure), further consideration should
be given to the risk of major bleeding from the procedure:

• i) If there is an acceptable perioperative bleeding risk (i.e. risk


of stroke outweighs risk of bleeding) the patient should have OAC therapy
continued perioperatively or have their OAC discontinued
before the procedure and be bridged with LMWH or UFH
perioperatively. (Conditional Recommendation, Low Quality Evidence)

• ii) If there is a substantial risk of major and potentially


problematic bleeding (i.e. risk of bleeding and risk of stroke are both
substantial) the patient should have their OAC discontinued before the
procedure with LMWH or UFH bridging until 12-24 hr preprocedure. Once
post procedure hemostasis is established (about 24 hr) the OAC should
be reinstated with LMWH or UFH bridging. (Conditional
Recommendation, Low Quality Evidence)

52 Leadership. Knowledge. Community.


Drug Management of Atrial Fibrillation
(Rate and Rhythm Control)
Atul Verma
Mario Talajic
Stanley Nattel
Paul Dorian
Anne Gillis
Leadership. Knowledge. Community.
Goals of AF Arrhythmia
Management
• Identify and treat underlying structural
heart disease and other predisposing
conditions
• Relieve symptoms
• Improve functional capacity/quality of life
• Reduce morbidity/mortality associated
with AF or AFL

54 Leadership. Knowledge. Community.


 We recommend that goals of ventricular rate control
should be to improve symptoms and quality of life
which are attributable to excessive ventricular rates.
(Strong recommendation, low quality)

 We recommend that the goals of rhythm control


therapy should be to improve patient symptoms and
clinical outcomes, and that these do not necessarily
imply the elimination of all AF.
(Strong recommendation, moderate quality)
55 Leadership. Knowledge. Community.
Rate or Rhythm Control?
• How do you decide if you are going to pursue rate
or rhythm control for a patient with AF?
• No right or wrong answer
• Often, the two are simultaneous:
– Rhythm control requires good rate control when
patient goes back into AF
• Need to continuously re-evaluate the strategy as
the AF progresses
– What may have been a good initial strategy may no
longer be warranted

56 Leadership. Knowledge. Community.


Favors Rate Control Favors Rhythm Control
Persistent AF Paroxysmal AF
Newly Detected AF
Less Symptomatic More Symptomatic
>65 years of age < 65 years of age
Hypertension No Hypertension
No History of Congestive Heart Congestive Heart Failure clearly
Failure exacerbated by AF

Previous Antiarrhythmic Drug No Previous Antiarrhythmic Drug


Failure Failure

57 Leadership. Knowledge. Community.


Rate Control of AF
• Primary goal is to improve symptoms and
prevent deterioration of cardiac function
associated with excessively rapid
ventricular rates during AF or AFL
– Tachycardia induced cardiomyopathy

• What is the target?

58 Leadership. Knowledge. Community.


RACE II Trial
• Suggested that strict rate control (< 80 at
rest, < 110 with exercise) was no different
compared to lenient strategy (< 110)
• However, actual HR in both groups were 75
and 86 respectively
• Thus, the trial was not that lenient
• Few patients had HR > 100 bpm

59 Leadership. Knowledge. Community.


Heart Rate Target
2010 CCS Guidelines We recommend that treatment
for rate control of
persistent/permanent AF or AFL
should aim for a resting heart
rate of less than 100 bpm
(Strong recommendation, high
quality)

2010 ESC Guidelines Lenient rate control protocol


aimed at resting HR <110 bpm.

Adopt a stricter rate control


strategy
when symptoms persist or
tachycardiomyopathy occurs,
despite
60 lenient rate control:
Leadership. HR <80
Knowledge. Community.
bpm and
Agents for Rate Control
• Beta-blockers
• Non-dihydropyridine calcium channel blockers
– Diltiazem, Verapamil
• Digoxin, digitalis
– Reserved for sedentary, LV dysfunction, second-line therapy
• Dronedarone
– Second line therapy
• Amiodarone
– Avoid using unless exceptional circumstances

61 Leadership. Knowledge. Community.


Rhythm Control of AF
• Strategy of rhythm control has never been
shown to reduce mortality compared to rate
control (AFFIRM, RACE, PIAF trials, AF
CHF)
• Therefore, goals of rhythm control should
focus on improving quality of life
• Rhythm control does not necessitate
elimination of all AF

62 Leadership. Knowledge. Community.


 We recommend a rhythm control strategy for patients with AF or AFL who remain
symptomatic with rate control therapy or in whom rate control therapy is unlikely to
control symptoms. (Strong Recommendation, Moderate Quality Evidence)

 We recommend that the goal of rhythm control therapy should be improvement in


patient symptoms and clinical outcomes, and not necessarily the elimination of all AF.
(Strong Recommendation, Moderate Quality Evidence)

 We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy


for patients with recurrent AF in whom long-term rhythm control is desired (see flow
charts). (Strong recommendation, Moderate Quality Evidence)

63 Leadership. Knowledge. Community.


Normal Ventricular Function

Dronedarone
Flecainide*
Propafenone*
Sotalol

Catheter Ablation

Amiodarone

* Class I agents should be AVOIDED in CAD


They should be combined with an AV-nodal blocking agents
64 Leadership. Knowledge. Community.
2010 ESC Guidelines

65 Leadership. Knowledge. Community.


What About LVH?
• 2010 ESC and 2006 AHA guidelines both do not
recommend class Ic agents or sotalol with
significant LVH
• Data supporting this recommendation is very
weak
• Only worry about it if abnormal repolarization is
seen on the ECG
• Otherwise, LVH is not a contraindication in and of
itself

66 Leadership. Knowledge. Community.


Is Dronedarone Distinct?
2010 ESC Guidelines

• ATHENA trial did show that dronedarone reduced


hospitalization or death in patients with AF
• However, one trial – effect mediated by rate
control?
• Rhythm control efficacy similar to sotalol
• Decided to include it as a choice, but no distinct
status in 2010 CCS guidelines

67 Leadership. Knowledge. Community.


Pill in Pocket Therapy
 We recommend intermittent antiarrhythmic drug
therapy ("pill in pocket") in symptomatic patients with
infrequent, longer-lasting episodes of AF or AFL as
an alternative to daily antiarrhythmic therapy.
(Strong Recommendation, Moderate Quality
Evidence)
– Single dose flecainide (200-300 mg) or propafenone
(450-600 mg) as an oral dose
– Often prescribed with a short-acting beta-blocker at the
same time (metoprolol 50-100 mg)
68 Leadership. Knowledge. Community.
Rhythm Control Does Not
Replace Anticoagulation
• No evidence that AF reduction via
antiarrhythmic therapy reduces the risk of
stroke/thromboembolism
• Patients must continue on appropriate
anticoagulation according to their
individual embolic risk (CHADS2 score)

69 Leadership. Knowledge. Community.


THANK YOU

70 Leadership. Knowledge. Community.

You might also like