Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Atrial fibrillation:
Why is it so Important in
Clinical Practice?
Ashish Nabar
Mumbai
AF: CLINICAL IMPORTANCE!AF: FAST, IRREGULAR, AV DYSSYNCHRONY
Atrial fibrillation:Clinical Importance
• Control of symptoms
• Prevention of stroke
(thrombo-embolism)
• Prevention of tachycardia-
induced cardiomyopathy
• Improved survival
I. PHARMACOVERSION OF SYMPTOMATIC ACUTE AF
• ED CARDIOVERSION FOR AF F/B
DISCHARGE IN SR: SAVES
HOSPITALIZATION COSTS
• PHARMACOVERSION LESS RESOURCE
INTENSIVE (PROCEDURAL SEDATION)
• AMIODARONE: HOURS,
IBUTILIDE, VERNAKALANT: MINS
ACUTE AF CONVERSION: CONSIDER IBUTILIDE
ACUTE AF CONVERSION: VERNAKALANT
EARLY CONVERSION SAFE CONVERSION
ATRIAL FIBRILLATION: MAINTAINING SINUS RHYTHM
II. AF is a Thromboembolic Risk!!
5-FOLD Increase STROKE risk
3-FOLD Increase HF risk
2-FOLD Increase DEMENTIA and MORTALITY
Multiple HOSPITALIZATIONS
AF:
Preventing thrombo-embolism
Even under rhythm
control strategy,
probably due to
asymptomatic AF
episodes, stroke risk
continues to be present
and appropriate anti-
thrombotic therapy must
be continued.
ASPIRIN is NOT EFFECTIVE
FOR STROKE PREVENTION in
pts with AF and in fact, may
increase the risk of stroke in
elderly pts, so it is therefore no
longer recommended for this
purpose.
NVAF & Stroke Prevention:
Risk score decides, not the clinical type!
NVAF & Stroke Prevention:
Weigh the Bleeding risk
HAS-BLED Scoring system
VKA: 60 years of use!Yet under-prescribed, barrier to stroke prevention
Average TTR = 63%
Stroke & Mortality risk
decreased if TTR >70%
AF & Stroke Prevention: NOAC
NOACs are non inferior to Warfarin
to prevent stroke and systemic embolic events
Superior safety compared to Warfarin
less ICH
however, slightly increased risk of GI bleeding
Versatile use
No laboratory monitoring
Limitations
Dose adjustments, if CKD
AF with other cardiovascular conditions, must await trial
results
Limited availability of reversal agent
AF & Stroke Prevention: NOACs
NOAC for NVAF following PCI:
Figure 1. AF and heart failure (HF): a vicious pathophysiological cycle.
III. AF & HF: A 2-way relation!
AF: Risk Factor for HF or Marker of Advanced HF?
• Large HF trials (SOLVD, VALIANT, COMET)
– Baseline AF is a negative prognostic marker
• All cause mortality, Progressive pump failure and combined
end point of death or HF hospitalization increases
– New onset AF carries a poorer prognosis (80%
mortality) than no / persistent AF (60-65%)
• Clinical and hemodynamic worsening, risk of systemic TE,
inadequate rate control
AF in HF: How best to treat?Intuitively Rhythm Control!
• Pharmacotherapy:
– Amiodarone, Sotalol, and Dofetilide: Conditionally safe
– Never use of Class I AADs: Risk of TdP
• Amiodarone:
– Safe and effective
– risk for symptomatic bradycardia
• Sotalol:
– For mild LV systolic dysfunction
Rhythm Controlling AF:Electrical Cardioversion: Don’t be SHY!
• Pharmacotherapy unlikely to convert AF >48 hours
duration
• Preferred as a test / term solution:
– New onset AF, LA size <45mm, Hemodynamically
compromised patient
• Avoided:
– Long standing AF, Large LA, Severe SHD
AF in HF: Ventricular Rate ControlIs it really Next Best!
• Optimal VR control:
– Resting HR: 60 to 80 bpm
– Moderate exertion: 90 to 115 bpm
– 24-hour Holter assessment
• Beta-Blockers :
– first choice: improves survival, controls VR
• Digoxin:
– Synergistic with BB
• Avoid CCB (Verapamil, Diltiazem): except in MS
Rate Control Intervention inAF:Ablation and Pacemaker Therapy
Pre-excited AF: Survival st Stake!
FBI: Pre-excited atrial fibrillation