1
Learning Objectives
After taking part in this activity, participants should
be better able to:
– Assess the significant clinical consequences and
burden of AF
– Apply new practice guidelines/best practices and
performance measures for the management of AF
– Interpret the latest clinical data on rate-control and
rhythm-control strategies for the management of
patients with AF
– Demonstrate an evidence-based approach for
reducing thromboembolic risk in patients with AF
2
Faculty Disclosure
The Network for Continuing Medical Education
requires that CME faculty disclose, during the
planning of an activity, the existence of any
personal financial or other relationships they or
their spouses/partners have with the commercial
supporter of the activity or with the manufacturer of
any commercial product or service discussed in the
activity.
Faculty and planner disclosure information is
included in the handout materials.
Epidemiology and
Burden of Disease
4
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Presentation
● A 65-year-old man presents with episodes of
palpitations, weakness, and significant
lightheadedness
● He describes his symptoms, which have been
occurring as often as 3 times each day for about 1
week, as severe and debilitating
5
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Medical History/Current Medications
The patient has been diagnosed with diabetes,
hypertension, and sleep apnea syndrome, and is taking
the following medications:
– Lisinopril 10 mg/d
– Metoprolol 50 mg/d
– Insulin (0.6 U/kg nightly)
6
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Physical Findings
● BP: 145/90 mm Hg; HR: 85 bpm
● Weight: 180 lb (82 kg); height: 5’10”; BMI: 25.9 m2/kg
● Chest auscultation and heart sounds
– Normal S1 and S2, no murmurs
– Irregularly irregular rhythm
● Abdominal examination findings: soft and nontender
7
Epidemiology of AF
● Most common sustained cardiac arrhythmia1
● Currently affects 5.1 million Americans2
● Prevalence expected to increase to 12.1 million by 2050
(15.9 million if increase in incidence continues)2
● Preferentially affects men and the elderly1,2
● Lifetime risk of developing AF: ~1 in 4 for adults 40
years of age3
1. Lloyd-Jones D, et al. [published online ahead of print December 17, 2009].
Circulation. doi:10.1161/CIRCULATIONAHA.109.192667.
2. Miyasaka Y, et al. Circulation. 2006;114(2):119-125.
3. Lloyd-Jones DM, et al. Circulation. 2004;110(9):1042-1046. 8
AF Is the Leading Cause of
Hospitalizations for Arrhythmia
Hospital Admissions in US
AF
AFL
Cardiac arrest
Conduction disease
Junctional
Premature beats
Sick sinus
Unspecified
VF
VT
0 200 400 600 800 1000
Hospital Days (thousands)
N=517,699 (representing 10% of CV admissions).
VF, ventricular fibrillation; VT, ventricular tachycardia.
Adapted from Waktare JE, et al. J Am Coll Cardiol. 1998;81(suppl 5A):3C-15C. 9
Mortality After Diagnosis of AF
100
4-month Post-4 months
80 HR, 9.62 HR, 1.66
Survival, %
60
40
MN-white expected
20 Observed
P0.40
0.25 No AF at baseline (Preserved)
0.20
0.15 Preserved EF (PEF):
Hazard ratio 1.72
0.10
(95% CI 1.45 – 2.06)
0.05 P7 days
• Both paroxysmal and
persistent AF can
become permanent
aTermination with pharmacologic therapy or direct-current cardioversion does not change the designation.
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 18
Clinical Evaluation
19
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
ECG Findings
20
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Echocardiogram Findings
● Mild LVH and nl LV function
– LV wall thickness 1.3 cm
– LA size 4.2
21
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
What other tests would you perform for
this patient at this time?
A. 6-Minute walk or exercise test
B. Holter monitoring/event recording
C. Electrophysiology study
D. Cardiac catheterization
E. Cardiac MRI
F. None
22
Clinical Evaluation for AF Patients:
Etiology, AAD Risk, Embolic Risk
● Treatment of AF is dependent on etiologic (cause, severity,
reversible/modifiable) as well a patient factors (embolic risk, concomitant
disorders)
● Some anatomic or functional disorders pose risks from AAD treatment (eg,
organ toxicity and ventricular proarrhythmia)
● At a minimum, an evaluation requires
– History – Echocardiogram
– Physical – Blood chemistries
– ECG – Stress test (if CAD is suspected)
– Chest x-ray (and possibly PFTs) if pulmonary disease is suspect
and/or HF is a consideration
● Current guidelines emphasize the prospectively determined CHADS2
risk-scoring system for embolic risk
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 23
Conditions Frequently Associated
With Nonvalvular AF1-4
● Hypertension
● Aging
● Male sex
● Obesity/metabolic syndrome/diabetes
● Ischemic heart disease
● Heart failure/diastolic dysfunction
● Obstructive sleep apnea
● Physical inactivity
● Thyroid disease
● Inflammation?
1. Wattigney WA, et al. Circulation. 2003;108(6):711-716.
2. Gersh BJ, et al. Eur Heart J Suppl. 2005;7(suppl C):C5-C11.
3. Fuster V, et al. J Am Coll Cardiol. 2006;48(4):854-906.
4. Mozaffarian D, et al. Circulation. 2008;118(8):800-807. 24
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
What is the patient’s diagnosis?
A. Paroxysmal AF
B. Persistent AF
C. Permanent AF
D. Other
25
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Would you recommend antithrombotic
therapy for this patient at this time?
A. Yes
B. No
26
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
If so, which risk stratification model
would you use to decide on the strategy?
A. ACCP
B. AFI (Atrial Fibrillation Investigators)
C. CHADS2
D. Framingham study
E. SPAF (Stroke Prevention and Atrial Fibrillation)
Investigators
F. Other
27
CHADS2 Risk Criteria for Stroke
in Nonvalvular AF
Risk Factors Score
C Recent congestive heart failure 1
H Hypertension 1
A Age ≥75 y 1
D Diabetes mellitus 1
History of stroke or transient ischemic
S2 attack 2
Gage BF, et al. JAMA. 2001;285(22):2864-2870. 28
Stroke Risk in Patients With Nonvalvular AF Not
Treated With Anticoagulation Based on the CHADS2
Index
Patients
(N=1733) (95% CI) CHADS2 Score
120 0
463 1
523 2
337 3
220 4 Warfarin
65 5
5 6
0 5 10 15 20 25 30
Adjusted Stroke Rate (% per y)
CHADS2, Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or
transient ischemic attack.
Gage BF, et al. JAMA. 2001;285(22):2864-2870. 29
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
If you were stratifying this patient’s risk
based on CHADS2, what score would he
receive?
A. 0
B. 1
C. 2
D. ≥3
30
Clinical Evaluation for Selecting
Antithrombotic Therapy
● Consider the following before selecting an anticoagulation strategy:
– Bleeding or thrombotic risk, history of/tendency for injuries
– Concomitant requirement for warfarin or antiplatelet therapy
– Drug compliance history and willingness for dietary compliance
– Concomitant therapies (including prescription drugs,
OTCs, herbals)
– Patient activities that risk injury or are contraindications
to warfarin
● Perform a clinical evaluation is prior to initiating anticoagulation strategy
● Testing the genetic pattern of warfarin metabolism may be helpful in
facilitating the initiation phase of warfarin therapy
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 31
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
What antithrombotic strategy would
you suggest?
A. Aspirin 80 mg/d
B. Aspirin 325 mg/d
C. Warfarin INR 2-3.5
D. Warfarin INR 1.5-2.5
E. Clopidogrel 75 mg/d + aspirin 80 mg/d
F. Dabigatran 110 mg/bid
32
Treatment
33
Treatment Goals and Strategies
Rate control Maintenance of SR Stroke prevention
Pharmacologic Pharmacologic Nonpharmacologic
• Ca2+ blockers Pharmacologic
• -blockers • Warfarin
• Digitalis • Aspirin
• Amiodarone • Thrombin Inhibitor
• Dronedaronea Class IAb Catheter ablation Nonpharmacologic
Class IC Pacing
• Removal/isolation
Class III Surgery
Nonpharmacologic LA appendage
• Ablate and pace -blocker Implantable devices
a Onlyin patients with nonpermanent AF; b the
CCB
Prevent Remodeling ACE-I, ARB antiarrhythmic drug classes are based on the
Vaughan Williams classification.
Statins
Fish oil
34
ACC/AHA/ESC 2006 Atrial Fibrillation Guidelines
Rhythm Control Therapies to Maintain Sinus Rhythm
Maintenance of SR
No (or minimal) Hypertension CAD HF
heart disease
Flecainide Substantial LVH Dofetilide Amiodarone
Propafenone
Sotalol Dofetilide
Sotalol
No Yes
Amiodarone Catheter Catheter Catheter
Dofetilide ablation Amiodarone
ablation ablation
Note: In 2009, the FDA approved
Flecainide Amiodarone
Propafenone dronedarone to reduce the risk of CV
Sotalol hospitalization in patients with paroxysmal or
Catheter
ablation
persistent AF or AFL, with a recent episode of
AF/AFL and associated CV risk factors, who
Amiodarone Catheter are in sinus rhythm or who will be
Dofetilide ablation
cardioverted. Consensus regarding its place in
the treatment paradigm is not yet available.
35
Reproduced with permission from Fuster V, et al. Circulation. 2006;114(7):e257-e354.
Individualized Patient Management
AF chronicity Pharmacologic
Paroxysmal
Persistent Maintain sinus
Chronic Catheter ablation
rhythm
AF symptoms Surgical maze
Aggravation of HF +/- valve/CAD surgery
Anticoagulation
Risk/benefit
Pharmacologic
Therapy tolerance
Risk/benefit Rate control
AVJ ablation
ICD or pacer
Courtesy of KA Ellenbogen, MD. 36
Rate Control
● End point
– Resting and ambulatory ventricular rates similar
to those expected in sinus rhythm
– Best assessed with Holter monitoring
– Determining pulse on exam and heart rate on
ECG are not sufficient
● Methods
– Digitalis: in sedentary patients or CHF
– β-blockers and/or CCBs (verapamil, diltiazem): needed in
most active individuals
– AVN ablation plus pacemaker: in resistant patients
● Special considerations
– Brady-tachy syndrome (pindolol, or pacer plus drugs)
– Preexcitation (focus on the BT as well as the AVN)
37
Cardioversion
Direct Current Conversion With Class IC Rx
– Biphasic is best Conversion Rates From AF to
(can do internal CV if needed) Sinus Rhythm at 3 and 8 Hours
Intravenous AAD
100%
– Ibutilide is best of the available drugs 3 hours
(2 mg/30 min; have MgSO4 available) 8 hours
– Amiodarone (≥1 g over 24 h) 80% 72%
– Procainamide, quinidine (44/61)
– Emerging drugs (eg, vernakalant)
60% 51%
Oral AAD 39% (31/61)
– Oral IC is best (70%-80% by 6-8 h; 40% (24/62)
mean, 1 moderate risk factorb
aFactors include prior stroke, TIA, or systemic embolism, rheumatic mitral stenosis, mechanical heart valve.
bAge ≥75 years, hypertension, diabetes mellitus, HF, or impaired LV systolic EF.
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 58
ACC/AHA/ESC 2006 Atrial Fibrillation Guidelines
Preventing Thromboembolism (cont)
I IIa IIb III
A INR should be determined at least weekly during initiation of therapy
and monthly when stable
A Aspirin, 81-325 mg daily, is recommended in low-risk patients or in
those with contraindications to oral anticoagulation
B
For patients with mechanical heart valves, the target intensity of
anticoagulation should be based on the type of prosthesis,
maintaining an INR of at least 2.5
C Antithrombotic therapy is recommended for patients with atrial flutter
as for AF
C
Long-term anticoagulation is not recommended for primary stroke
prevention in patients <60 years without heart disease (lone AF)
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 59
ACC/AHA/ESC 2006 Atrial Fibrillation Guidelines
Risk Stratification for AF:
Antithrombotic Therapy
Risk Category Recommendation
Low Risk Aspirin, 81-325 mg a day
No moderate-risk factors
CHADS2 = 0
Moderate Risk Aspirin, 81-325 mg a day
One moderate-risk factor or warfarin (INR 2.0-3.0)
CHADS2 = 1
High Risk
Any high-risk factor or ≥2 moderate-risk factors Warfarin (INR 2.0-3.0a)
CHADS2 = ≥2
aINR 2.5-3.5 for prosthetic valves. What to do about “weaker” risk factors?
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 60
Currently Available
Antithrombotic Agents
Warfarin
Low–molecular-weight heparin
Unfractionated heparin
Aspirin
Aspirin + clopidogrela
Dabigatran
a Not currently FDA approved.
61
Limitations of Warfarin
Limitations Consequences
Slow onset of action Overlap with parenteral anticoagulant
Genetic variation in metabolism Variable dose requirements
Multiple food and drug interactions Frequent coagulation monitoring
Narrow therapeutic window Frequent coagulation monitoring
Hirsh J. N Engl J Med. 1991;324(26):1865-1875.
Bates SM, Weitz JI. Br J Haematol. 2006;134(1):3-19.
Courtesy of PR Kowey, MD. 62
The ACTIVE Studies
ACTIVE-W1
– Compared warfarin (INR, 2-3) vs clopidogrel 75 mg/d + ASA
(75-100 mg/d) in high-risk AF patients
– 6706 patients randomized
– 1.28 years of follow-up
– Primary end point: stroke, systemic embolus, MI, vascular death
– Study stopped early due to superiority of warfarin
ACTIVE-A2
– Compared clopidogrel 75 mg/d + ASA (75-100 mg/d) vs ASA alone in
high-risk AF patients who could not or would not take warfarin
– 7554 patients randomized
– Same primary end point
– 3.6 years of follow-up
– Stroke occurred in 296 (2.4%/y) patients on clopidogrel + ASA and in
408 patients (3.3%/y) on ASA alone (RR, 0.72; P<.001). However, major
bleeding occurred in 251 (2.0%/y) patients on clopidogrel + ASA and in
162 (1.3%/y) patients on ASA alone (RR, 1.57; P<.001)
1. ACTIVE Investigators. Lancet. 2006;367(9526):1903-1912. 63
2. ACTIVE Investigators. N Engl J Med. 2009;360(20):2066-2078.
AHA/ASA 2010 Guidelines for the Prevention of Stroke
in Patients With Stroke or TIA
Recommendations for Atrial Fibrillation
I IIa IIb III
A Aspirin alone is recommended for patients
unable to take oral anticoagulants
B The combination of clopidogrel plus aspirin
carries a risk of bleeding similar to that of
warfarin and therefore is not recommended for
patients with a hemorrhagic contraindication to
warfarin (new recommendation)
Furie KL, et al. Stroke. [published online October 21, 2010]. doi:
10.1161/STR.0b013e3181f7d043. 64
RE-LY: Study Design
Nonvalvular atrial fibrillation at moderate
to high risk of stroke or systemic embolism
(at least 1 additional risk factor)
R
Warfarin
Dabigatran Etexilate Dabigatran Etexilate
1 mg, 3 mg, 5 mg
110 mg bid 150 mg bid
(INR, 2.0-3.0)
n=6000 n=6000
n=6000
Primary objective: noninferiority to warfarin
Minimum 1-year follow-up, maximum of 3 years and mean of
2 years of follow-up
Primary end point: stroke or systemic embolism
Connolly SJ, et al. N Engl J Med. 2009;361(12):1139-1151. 65
RE-LY: Primary Outcome
Reproduced with permission from Connolly SJ, et al; the RE-LY Steering Committee and
Investigators. N Engl J Med. 2009;361(12):1139-1151. 66
RE-LY: Bleeding Events
Dabigatran Dabigatran Dabigatran 110 mg vs Dabigatran 150 mg
Warfarin
110 mg 150 mg Warfarin vs Warfarin
Annual Annual Annual RR RR
P Value P Value
Rate Rate Rate 95% CI 95% CI
0.80 0.93
Major 2.7% 3.1% 3.4% .003 .31
0.69-0.93 0.81-1.07
Life-
0.68 0.81
threatening 1.2% 1.5% 1.8% <.001 .04
0.55-0.83 0.66-0.99
(major)
Gastro-
1.10 1.50
intestinal 1.1% 1.5% 1.0% .43 <.001
0.86-1.41 1.19-1.89
(major)
0.79
0.91
Minor 13.2% 14.8% 16.4% 0.74-0.84 <.001 .005
0.85-0.97
Major or 0.78 0.91
14.6 16.4% 18.2% <.001 .002
minor 0.74-0.83 0.86-0.97
Connolly SJ, et al; the RE-LY Steering Committee and Investigators. N Engl J Med.
2009;361(12):1139-1151. 67
Emerging Anticoagulants for
Stroke Prevention in AF
Direct factor Xa inhibitors
– Apixaban (AVERROES, ARISTOTLE)
– Betrixaban (EXPLORE Xa)
– Edoxaban (ENGAGE AF–TIMI 48)
– Rivaroxaban (ROCKET AF)
Vitamin K antagonists
– Tecarfarin
Usman MH, et al. Curr Treat Cardiovasc Med. 2008;10(5):388-397. 68
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Scheduled Follow-up Visit at 4 Weeks
● The patient continues to take dronedarone as
prescribed
● His ECG shows sinus rhythm without other
abnormalities
● He reports no side effects from the medication;
however, he continues to experience episodes of AF
2 to 3 times per week that last several hours at a
time, and complains of severe palpitations and
fatigue during the AF episodes
69
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
What treatment would you now
suggest?
A. Catheter ablation
B. Flecainide
C. Dofetilide
D. Amiodarone
E. AV node ablation and PPM
70
Surgical and Catheter Ablation
71
HRS/EHRA/ECAS 2007 Expert Consensus Statement on Catheter
and Surgical Ablation of Atrial Fibrillation
Indications for Surgical Ablation
● Symptomatic AF patients undergoing other cardiac surgery
● Selected asymptomatic AF patients undergoing cardiac surgery
in whom the ablation can be performed with minimal risk
● Symptomatic AF patients who prefer a surgical approach, have
failed 1 or more attempts at catheter ablation, or are not
candidates for catheter ablation
Best results are obtained in patients with paroxysmal AF
who are young and otherwise healthy
Calkins H, et al; Heart Rhythm Society Task Force on catheter and surgical
ablation of atrial fibrillation. Heart Rhythm. 2007;4(6):816-861. 72
Patient Selection for Ablation
Variable
Symptoms Highly symptomatic Minimally symptomatic
Class I and III drugs failed 1 0
AF type Paroxysmal Long-standing persistent
Age Younger (<70 years) Older (70 years)
LA size Smaller (<5.0 cm) Larger (5.0 cm)
Ejection fraction Normal Reduced
Congestive heart failure No Yes
Other cardiac disease No Yes
Pulmonary disease No Yes
Sleep apnea No Yes
Obesity No Yes
Prior stroke/TIA No Yes
Courtesy of Hugh Calkins, MD. 73
Initiation of AF From
Pulmonary Vein Focus
Reprinted with permission from Haissaguerre M, et al. N Engl J Med. 1998;339(10):659-666. 74
AF Is a Complex Arrhythmia
SVC
RSPV
LSPV
LIPV
RIPV
Vein and
ligament of Marshall IVC
Reprinted with permission from Calkins H, et al. Heart Rhythm. 2007;4(6):816-861. 75
Surgical and Minimally Invasive
Surgical Ablation
76
Cox-Maze Procedure
In a trial of 190 patients, 1987-1997:
92% had freedom from AF and were off AAD agents
Reprinted with permission from Sundt TM 3rd, et al. Cardiol Clin. 1997;15(4):739-748. 77
ACC/AHA/ESC 2006 Atrial Fibrillation Guidelines
Recommendations for Catheter Ablation
I IIa IIb III
Heart rate control:
B When pharmacologic therapy is insufficient or associated
with side effects
C When rate cannot be controlled pharmacologically or
tachycardia-mediated cardiomyopathy is present
C Should not be attempted without prior trial of medication
Rhythm control:
C Reasonable alternative to pharmacologic therapy to
prevent recurrent AF in symptomatic patients with little or
no LA enlargement
Fuster V, et al. Circulation. 2006;114(7):e257-e354. 78
HRS/EHRA/ECAS 2007 Expert Consensus Statement on Catheter
and Surgical Ablation of Atrial Fibrillation
Indications for Catheter Ablation
● Symptomatic AF refractory or intolerant to at least 1 Class
1 or 3 antiarrhythmic medication
● In rare clinical situations, it may be appropriate
as first-line therapy
● Selected symptomatic patients with heart failure and/or
reduced ejection fraction
● Presence of a left atrial thrombus is contraindication to
catheter ablation of AF
Calkins H, et al; Heart Rhythm Society Task Force on catheter and surgical ablation of
atrial fibrillation. Heart Rhythm. 2007;4(6):816-861. 79
Efficacy of Catheter Ablation in
Patients With AF
Meta-analyzed Proportion of Patients, % 90
42 (3,562)
75 34 (3,481) 52 (4,786)
31 (2,800)
60
45
30 57% 71% 72% 77%
15
0
Single- Multiple- Single- Multiple-
procedure procedure procedure procedure
success success success success
off AAD off AAD on/off med on/off med
Adapted with permission from Calkins H, et al. Circ Arrhythmia Electrophysiol. 2009;2(4):349-361. 80
Catheter Ablation of the AV Junction
Advantages
– Simple
– Highly effective
– Safe
– Allows a reduction in
medication
– Reduces symptoms
But:
– Does not prevent AF
– Does not restore a normal
heart rhythm
– Requires placement of a
pacemaker
– Does not lower the risk
of stroke
81
Catheter Ablation of AF: Meta-analysis
of 4 Randomized Clinical Trials
Source Risk Ratio % Weight
(95% CI)
Pappone et al, 2006 3.86 (2.65-5.63) 37.5
Stabile et al, 2006 6.43 (2.91-14.21) 18.1
Wazni et al, 2005 4.22 (2.14-8.32) 22.0
Krittayaphong et al, 2003 2.00 (1.02-3.91) 22.4
Overall (95% CI) 3.73 (2.47-5.63)
0.04 0.20 1.00 5.00 25.00
ADT More Effective CPVA More Effective
Risk Ratio
Reproduced with permission from Noheria A, et al. Arch Intern Med. 2008;168(16):581-586. 82
NaviStar® ThermoCool®
Diagnostic/Ablation Catheter
● Steerable, multi-electrode, deflectable
● 3.5-mm tip and 3 ring electrodes
● 6 saline ports in the tip for irrigation and cooling (open irrigation)
● A location sensor and a temperature sensor incorporated into the tip
● Approved by the FDA on February 6, 2009, for treatment of AF
83
ThermoCool® Catheter vs AAD:
Freedom From AF Recurrence Time to Chronic Failures
1.0
0.8
64% Ablation
0.6 (n=103)
0.4 P<.001
0.2 16% AAD
(n=56)
0.0
0 30 60 90 120 150 180 210 240 270 300 330 360
Days Into Effectiveness Follow-up
Number of subjects at risk:
Ablation 103 69 69 66 63 62 61 54 52 37 15 3 2
AAD 56 39 29 19 16 13 11 10 7 2 0 0 0
Effectiveness cohort, N=159. Circles in the graph represent 14 censored catheter ablation subjects.
Wilber D. Presented at: American Heart Association 2008 Scientific Sessions;
November 11, 2008; New Orleans, LA. 84
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
Catheter Ablation and Follow-up Visit at
3 Months
● The patient undergoes successful catheter ablation
● On follow-up 3 months post-catheter ablation, he is in
AF and reports that AF recurred about 3 weeks
following the ablation procedure and has been
present constantly since that time
● He complains of continued palpitations and fatigue
● An ECG confirms the presence of AF
85
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
What treatment would you now
suggest?
A. Repeat catheter ablation
B. MiniMaze procedure
C. DCC
D. Pharmacologic cardioversion
E. Amiodarone
F. AV node ablation and PPM
86
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
DCC and Follow-up Visit at 6 Months
Post-Catheter Ablation
● The DCC was successful in restoring sinus rhythm
● At a 6-month follow-up visit after the catheter ablation,
the patient reports 1 episode of AF each month lasting
approximately 20 minutes
87
Case:
65-Year-Old Man With Recent Episodes of Palpitations,
Weakness, and Lightheadedness
At this point, what treatment would you
suggest?
A. Repeat catheter ablation
B. MiniMaze procedure
C. DCC
D. Pharmacologic cardioversion
E. Dronedarone
F. AV node ablation and PPM
G. Clinical follow-up
88
Possible “Upstream” Treatments and
Mechanisms for AF Prevention
ACEIs/ARBs Statins Glucocorticoids Physical activity Omega-3 fatty acids
Inflammation Oxidative stress RAAS activity Endothelial function
Autonomic nervous system activity
Plaque stability Atrial remodeling Stabilize left atrial endocardium
Atrial fibrillation
Courtesy of CJ Pepine, MD. 89
2010 ESC Guidelines
for the Management of
Atrial Fibrillation
90
2010 Guidelines for the Management of AF
The Task Force for the Management of AF of the
European Society of Cardiology (ESC)a
New recommendations
● Addition of “long-standing persistent AF” as a
patient category
● Introduction of the EHRA symptom score for arrhythmias
● Establishment of better risk profiles to assess who will benefit
most from new anticoagulants to prevent stroke
– CHA2DS2-VASc score (refinement of CHADS2 score)
– HAS-BLED (new score for assessing bleeding risk)
a Developed together with the European Heart Rhythm Association (EHRA) and endorsed by the
European Association for Cardio-Thoracic Surgery (EACTS).
Camm AJ, et al. Eur Heart J. 2010;31:2369-2429. 91
2010 Guidelines for the Management of AF (cont)
The Task Force for the Management of AF of the
European Society of Cardiology (ESC)a
Changes from the previous ACC/AHA/ESC
2006recommendations
● New guidance in the area of rate control
● Advice on how to use the antiarrhythmic drug dronedarone
● Formal indications for the use of ablation therapy
● Recommendations on “upstream” therapies to prevent the
deterioration of AF
● Advice on certain “special situations”
a Developed together with the European Heart Rhythm Association (EHRA) and endorsed by the
European Association for Cardio-Thoracic Surgery (EACTS).
Camm AJ, et al. Eur Heart J. 2010;31:2369-2429. 92
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Question-and-Answer
Session
111
AF Performance Improvement
Outcomes Study
● NCME has partnered with Harvard Clinical Research Institute (HCRI) to
evaluate the impact of this educational activity
● The goal of the study is to:
– help each participating hospital gain perspective on how their
institution manages AF
– directly assess improvements in patient outcomes
● Data will be collected via a secure online Web site
● Baseline data will be collected representing a period prior to the grand
rounds lecture, and then one year as a follow up
● Study closely aligns with QI programs your hospital is already involved
in (eg, reporting to Joint Commission and CMS)
● $500 honorarium will be provided to each participation institution
● To sign up for the study complete the enrollment form provided to
your CME coordinator or send an e-mail message to
AFIBstudy@ncme.com 112
Thank you
for participating!
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