Professional Documents
Culture Documents
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
Single-center, prospective, study of 269 pts with atrial fibrillation treated with warfarin
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.
Patients with elevated D-dimer levels experienced higher thromboembolic and combined
cardiovascular events.
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%
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
* p=0.79
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 .
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
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
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
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:
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
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
mo.
2.00
1.50
1.00
r aey r e p %
0.50
0.00
D110 mg BID D150 mg BID Warfarin
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.
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.
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.
Dronedarone
Flecainide*
Propafenone*
Sotalol
Catheter Ablation
Amiodarone