Upload
praveen-nagula
View
2.403
Download
4
Embed Size (px)
DESCRIPTION
ATRIAL FIBRILLATION THE GRANDFATHER OF ARRHYTHMIAS..
Citation preview
ATRIAL FIBRILLATIONDr. Nagula Praveen
Management
GOALS: Prevention of stroke Prevention of tachycardia induced
cardiomyopathy Symptom relief Improved survival Primary prevention
Three strategies
Rate control – in all patients with AF Rhythm control – in selected patients with AF Prevention of thrombo embolism
Management
MEDICAL 1.ANTIARRHYTHMIC DRUGS 2.AV NODAL BLOCKING DRUGS 3.ACEI 4.ARBS 5.STATINS 6.FATTY ACIDS 7.STEROIDS SURGICAL —MAZE PROCEDURE ABLATION PACEMAKER ANTI THROMBOTIC TREATMENT
Anticoagulation
Risk stratification Peri cardioversion
RISK FACTORS Highest risk of stroke >6% /yr Valvular 15- 20 times the nonvalvular Prosthetic valves 2.5-3.5 MVR – 2.0- 3.0 previous h/o TIA/stroke
Intermediate risk factors ---3—5 % /yr CHA2DS2VASc score One intermediate risk factor present HTN Diabetes Age
• Lone AF lowest risk < 2% yr
FRAMINGHAM RISK SCORE
CHA2DS2VASc SCOREFACTOR POINTS/MAX SCORE---
9
1. C CONGESTIVE HEART FAILURE
1
2.H HYPERTENSION 1
3. A AGE> 75 YRS 2
4. D DIABETES 1
5. S2 PRIOR STROKE/TIA 2
6.V VASCULAR DISEASE 1
7.A AGE 65-74 1
8.Sc SEX CATEGORY(F) 1
THERAPY ACCORDING TO RISK FACTORS
Pericardioversion
AF ---- mechanical stasis in atria, atrial appendage.---pro inflammatory state--- pro thrombotic state.
Unstable thrombus – dislodge on contraction. Atrial mechanical function lags behind electrical
function. Atrial mechanical stunning --- 4 weeks
JACC 1989 If not risk of event – 5%
If > 48 hrs Empiric anticoagulation for 3 weeks. Short term anticoagulation : TEE guided
Why 3 weeks – organisation of thrombus Warfarin?--- target 2.5 Do weekly INR before cardioversion. Low INR more events
JACC;2002;40(5)
Heparin followed by TEE – thrombus present --- warfarin for three weeks .
Post cardioversion for 4 weeks. Then based on risk factors assess the risk
Most occur in < 72 hrs. Not needed in < 48 hrs. Symptoms are unreliable--- ECG documentation
needed…otherwise assume > 48 hrs..
Newer agents Why? Disadvantage of OAC Inter individual variation Drug /food interactions Regular INR check up needed--- monthly. DABIGATRAN (pradaxa)--- direct thrombin inhibitor REL –Y trial --- same as warfarin in stroke prevention Higher dose more effective but with risk of bleeding. No INR monitoring,150-220 mg daily FDA approved------- NEJM
2009 361(2);1139-51 RIVAROXABAN (xaretto)--- factor X a inhibitor Related to linezolid,mitochondrial toxicity ROCKET AF trial
Other ways
LAA occlusion Most common source of embolism WATCHMAN device PROTECT AF trial Periprocedural complications more Used when OAC contraindicated lancet
2009 ;374;534--40
RATE VS RHYTHM CONTROL
Theoretically rhythm control > rate control But complications anti arrhythmic drugs. End points RESULTS
All causes mortality no difference
CV mortality no difference
Non cardiovascular mortality
more with rhythm
stroke no difference
Quality of life no difference
Cost rhythm control less cost
Outcome
AFFIRM
better in STAF J RHYTHM trials
RHYTHM
CHOICE OF STRATEGY
FAVORS RATE CONTROL RHYTHM CONTROL
Persistent AF paroxysmal AF
Recurrent AF First episode
Less symptomatic More symptomatic
> 65 yrs < 65 yrs
HTN No HTN
No h/o CHF h/o CHF
Previous rhythm treatment failure.
Patient preference
Rate control drugs
Atrioventricluar blocking agents Calcium channel blockers Beta blockers Amiodarone Digoxin
ABCD
Rate control
Bblockers , CCBs , digoxin are effective for rate control.
Do not convert AF into NSR. C/I in pre excitation Amiodarone for both rate and rhythm control. Several side effects limits its use as first line drug.
Choice of drugs depends upon the clinical presentation
Normal systolic function:
IV CCBs non dihydropyridine group IV BBs --- class I recommendation
LVD or HF : IV digoxin or IV amiodarone –class I recommendation In case of AV nodal blocking agents C/I
DILTIAZEM: Chemical defibrillator 0.25 mg /kg (15-20 mg ) given IV over 2 minutes. Monitor HR and BP Rapid onset of action –within 10 min 0.35 mg /kg (20-25 mg )IV over 4 min HR < 100bpm ---maintenance dose 5-15 mg /hr is
infused t1/2 3-4 hrs Oral dose within 3 hrs of IV dose. 1.5 * total IV dose 120-360 mg three to four divided doses SR prepartion is useful in case of OD
VERAPAMIL: 0.075-0.15 mg /kg (5-10mg) given IV over 2 min Same if needed after 15 to 30 min T ½ -- 4-12 hrs. No need of continuous maintenance infusion More hypotensive and more negatively inotropic than
diltiazem. Hypotension responds to IV calcium gluconate 1 gm. Oral maintenance does is 120-360 mg in divided
doses.
Beta blockers
In myocardial ischemia Thyrotoxicosis Class I recommendation• Metoprolol: Selective B1 blocker 2.5 -5 mg IV over 2 min .. Up to three doses ( max 15
mg) Oral maintenance dose of 25-100mg (50 mg) bid • Atenolol– use in hypertension 5mg IV—50 mg od• Propanolol – 0.15 mg /kg -- 80 -240 mg /day• Esmolol--- 0.5mg/kg over I min 60- 200mcg /min
digoxin
Not used when LV function is preserved. In hypotension In COPD LVD Class 1 recommendation Not effective as monotherapy. Not useful in exercise and thyrotoxicosis
amiodarone
• Class II a recommendation in case of preserved LV Function
• Class II b recommendation when rate control is not achieved by other agents.
Patients with LVD
• Digoxin: 0.25 mg IV over 2 min every 2 hours. Not to exceed 1.5 mg IV over 24 hrs Maintenance dose is 0.125-0.375 mg daily IV or orally.
Orally 0.5 mg daily for 2-4 days— 0.125– 0.375 mg daily
Slow onset of action Effective in controlling heart rates at rest as well as
in individuals who are sedentary But not so in adrenergic stress,hyperthyroidism,copd?
Amiodarone: Acute setting 150 mg IV over 10 min maintenance infusion of 1 mg/ min IV over 6 hrs , 0.5 mg /min IV over 18 hrs.. Orally ,late onset of action – not in acute setting Oral dose is 800 mg /day in divided doses /week Oral maintenance dose 200mg daily. Affects the pharmacokinetics of digoxin , warfarin ,
verapamil — reduced dose
WPW SYNDROME
Use of AV nodal blocking agents is dangerous. Allows the fibrillatory waves to pass freely through
the bypass tract--- VF Type Ia agents which increase refractory period of
bypass tract –procainamide Inhibit both AV node and bypass tract– type Ic and
type III ibutilide or amiodarone IV to control ventricular rate.
Or else use EC
Non pharmacologcial control of VR in AF
In case of tachycardia induced cardiomyopathy
AV nodal ablation : if the VR in AF cannot be controlled by AV Nodal blocking agents AV nodal ablation with permanent ventricular pacemaker is an option
• Agents should be tried
Pulmonary vein isolation:• Surgically or RFA
NO STRUCTURAL HEART DISEASE DILTIAZEM, VERAPAMIL, BB
CAD, EF > 40 % BB ,CCB S
LVD EF < 40 % DIGOXIN ,BB s
REFRACTORY CASES AMIODARONE,DRONEDARONE,AV NODAL ABLATION
What is effective rate control?
At rest HR , 80 /MIN HOLTER MONITROING rest --- < 80/min no hour averaging ----- 90 / min Moderate exercise 90 – 115 /min Peak exercise 120 /min 20- 30 % REDUCTION of age predicted HR
RATE CONTROLLING DRUGS
Rhythm control
Not necessary in all patients In AFFIRM trial (Atrial Fibrillation Follow up
Investigation of Rhythm Management) RACE Rate control vs Electrical Cardioversion for
Persistent Atrial Fibrillation No change in mortality or incidence of stroke in both
groups.
Symptomatic and LVFpatients
Methods
Electrical cardioversionPharmacological cardioversion• Risk of thromboembolisation • Increased if > 48 hrs.
• Spontaneous conversion – many patients of AF• Mostly during the first 24-48 hrs.• Less as duration prolongs• Very less > 7 days• Efficacy of drugs also decrease.
Cardioversion
Electrical or pharmacological When? Which is better? In whom?
When --- symptomatic AF,newly AF,post op AF Which -------- electrical > pharmacological Whom? ------- persistent,paroxysmal
Do all need ?
Severely symptomatic ,less severe symptomatic acute AF --- to be cardioverted…..
“restoration of SR is a reasonable goal in patients who have a first time diagnosis of AF regardless of symptoms unless some indications shows that AF has been prsent for many years before identification…….” CARDIOLOGY CLINICS
In asymptomatic to slow progression of AF
Duration of paroxysmal event progression of AF Effective in short duration AF Not useful in old , asymptomatic Therapeutic anticoagulation in all.. Biphasic > monophasic Even in presence of structural heart disease.
Electrical cardioversion
Success – adequate current flow Biphasic > monophasic Deep sedation required. No effect of pad size or paddle positioning. Shock delivery not during vulnerable phase---VF In synchronized mode— R wave sensing. In defibrillation mode --- in an asynchronous
fashion. 200/360 J In emphysema,obesity,asthma---expiratory
phase
Implanted devices --- AP postioning Why?--- no effect on device. Device commanded cardioversion. In AFL –antitachycardio pacing is required,no
sedation. Internal cardioversion --- by catheters—rt
atrium,LCS,LPA.
Aftercardioversion
Persistent restoration of AF IRAF Failed cardioversion
IRAF---immediate recurrence of AF 5%-25% Triggered by APCs Pretreatment with fleicainide useful. Failed cardioversion – 10 % Amiodarone,ibutilide useful.
Positoning of paddles
RHYTHM CONTROL DRUGS
Theoretically useful Less symptoms Good effort tolerance Less hospitalisations But more compications by drug itself
Pharmacolocigal cardioversion
No IV sedation < 7 days of onset Less effective than electric Toxic effects of drugs
Type Ia agents – procainamide,quinidine,disopyramide
Type Ic agents – propafenone , fleicainide Type IIIagents -- ibutilide, dofetilide amiodarone
Hospitalised Exception is amiodarone
Type Ia and Ic convert AF –AFL BB or CCBs to be given half n hour before them.
Agents • AF< 7 days : Class I recommendation Class Ic fleicainide or propafenone Class IIa Class III dofetilide or ibutilide Class IIb – amiodarone class III --- sotalol,digoxin
Preserved systolic function
Flecainide: Class I recommendation Orally or IV 200-300 mg given once Only after effective response in hospitalisation –pill in
pocket approach to be used. IV Dose is 1.5 -3.0 mg/kg given over 10-20 min
Propafenone: Class I recommendation Oral –600mg given once IV dose 1.5-2.0 mg /kg over 10-20 min 56-83%
Ibutilide: IV only 1 mg over 10 min Dose repeated
Dofetilide: c/I in renal dysfunction 500 mcg bid 500-100 mcg daily QT interval to be monitored
Amiodarone: 5-7 mg/ kg IV over 30- 60 min 1.2 -1.8 g/day of infusion—10 gms 200-400mg/day is maintenance
Quinidine: 0.75-1.5 gm in divided doses Digitalis toxicity
In LVD
Only amiodarone and dofetilide 100-400 mg daily
>7 days: Class III agents are effective
Choice of anti arrhythmic drugs in the treatment of AF with assosciated co morbidities
Lone AF CHF CAD LVH
1st line Fleicainidepropafenone
Amiodaronedofetilide
Sotalolamiodarone
amiodarone
2nd line SotalolAmiodaroneClass Ia
Class Ia dronedarone disopyramide
avoid Fleicainidepropafenone
Fleicainidepropafenone
In brief
Short duration AF --- highly symptomatic , no structural heart disease.
Adjunctive therapy For short duration –class Ic drugs Pill in pocket approach only after intial
hospital response --- based on symptoms prsent outside,
>70 kg--- flecainide 300mg, propafenone 600mg <70 kg --- flecainide 200 mg , propafenone 450
mg Long duration 20-30 % cases
Surgical ablation: Maze procedures –atrial incisions In conjunction with other surgical operations Replacemnt of mirtal valve CABG
Pacemakers
RV placed pacemaker.. Prevents AV asynchrony Prevents reentry Prevents bradycardia induced dispersion of atrial
depolarisation.
Other drugs
Beneficial role ACEI ARBS Prevents structural remodelling. Blocks RAAS STATINS OMEGA 3 FATTY ACIDS VITAMIN C STEROIDS RANOLAZINE-RANEXA --- MERLIN AF TRIAL Na channel blocking drug..
New drugs
DRONEDARONE( multaq):sanofi aventis Amiodarone like compound Lacks iodine moiety Spans all classes K currents,INa,Ikr,Ikach,L type ca ,β blocking,prolongs AP, T ½ --24 hrs Dronedarone AF study after EC—prevention of AF 800mg
optimal dose. ANDROMEDA study– tolerability in CHF DANE trial ADONIS,EURIDIS 400mg bid
CELIVARONE: SSR 149744C Benzofuran derivative Structurally related to amiodarone Inhibits k currents 300mg or 600 mg. ATI 2001 Synthetic analogue of amiodarone More potent than amiodarone in atrial properties T1/2 –12min
Class III drugs
AZEMILIDE: 125 mg daily Neutropenia,torsades de pointes TEDISAMIL: Multiple k channels Decreases rate Increases AP in atria Antianginal drug BERTOSAMIL on clinical trials
Atrial depolarization delaying agents
• VERNAKALANT Na ,k blockers Atrial selectivity 61 % conversion 3mg/kg over 10 min --- 2 mg /kg Dysguesia,nausea,vomting• AVE 0118 Ikur,ito,ikach No QT prolongation• AZ7009• SEROTONIN type 4 antagonists• RS 100302
New drugs
Adenosine agonists CVT –510 : Slowed av conduction No negative inotropic ,vasodialtion,hypotension
effects.
Ambasilide Almokalant Sematilide Tedisamil Ximelgatran –SPORT IF trial Rotigaptide---gap junction modulator
WHAT DOES TRIALS SAY?
AFFIRM trial : RACE trial : AF –CHF trial ALL reveal no change in mortality in both groups. Treatment is individuialised
AFFIRM trial : management of AF with the rhythm control strategy offers no survival advantage over the rate control strategy.anticoagualtion to be continued in this group of high risk patients .
ATHENA trial :a trial with dronaderone to prevent hospitalisation or death in AF
400mg bid dose ANDROMEDA –european trial of dronedarone in
moderate to severe CHF---400 mg bid CAFÉ trial : canadian AF evaluation study. SAFIRE –D study –doefetilide use in AF 500ug dose. CRAFT REL-Y TRIAL 110mg -150 mg of dabigatran. RECOVER –in dvt ROCKET AF –rivaroxaban EINSTEIN ---vte ATLAS ACS –in ACS
trial Follow up
No. of subjects
AF charct
Rhythm control
Ratecontrol
1 endpoints
Summaryresults
PIAF2000
I yr 252 Persistent7d-1yr
AmioECV
Dil,BB,Dig,RFA
Sym .improve
No diffRhytm=↓FC,rate=↓h
PAF22002
1.3y 141 Paroxysmal,severe sym.
A,pro,flc,sot:ECV
RFA Dev of Per.AF
RH=↓pAFRate=↓CHF
AFFIRM2002
3.5y 4,060 Persistentparoxysm
A,S,P,AAD:ECV,non pharm
BB,D,V,dig,RFA
death No diif in end point
RACE 2002
2.3y 522 Pers(32d)recAFaftrECV
S,F,P,A:ECV
BB,D,V,dig,RFA
Composite cl.evnts
Rate nt inferior fr 1 end point
STAF 2003
1.7y 200 Persistent>4wks
A,P,F:ECV BB,D,V,dig,RFA
composite
No change
HOTCAFÉ2004
1y 205 Persistent7d-2yr
ECV-P,S,digRec-rpt,A
BB,dig,v,RFA
Composite
No difference
Ongoing trials/new trials 625 trials so far 1.Apixaban– novel factor X a inhibitor 5mg bid AVERROES study –phase III Compared with aspirin Double blinded RCT 2.efficacy of olmesartan in paroxysmal AF ANTI PAF trial –40 mg OD 3.EPLERAF study ---eplerenone in the prevention of AF
recurrence after cardioversion 4.vernakalant hcl efficacy in AF 5.WISDOM trial –withdrawal or continuation of amiodarone
in successfully treated patients with persistent AF 6.w 3 fatty acids for prevention of post OP AF--- OPERA
Recent advances
ACC/AHA 2010 guidelines How to handle rate control therapy Recently introduced antiarryhtmic drugs Catheter based treatment Antithrombotic therapy No benefit of achieving strict heart rate control <80
bpm at rest <110 bpm on exer cise ---class IIIevidence b
Dronedarone not to be used in LVD Catheter ablation –class Ia –A evidence in paroxysmal
Afnormal atria,class II b --- paroxysmal with LVD,Iia –persistent
Dabigatran –seminal event in AF management
Take home message
Most common sustained cardiac arrhythmia All three properties of arryhtmia play a role. Foci of intiation diagnosed. Treatment depends upon duration. Treatment changes on age,presence of LVD Anticoagualtion or antithrombotic based on assessment of
risk factors.. Rate control = rhytm control on long term theoretically rhythm control is better. Not useful in permanent AF. Catheter ablation is becoming the major option in treatment. Effects of antiarryhthmic drugs are overcome by new drugs. INR need not be monitored witn dagibatran
Ganong Samson and wright physiology Guyton www.emedicine.com www.aha.org www.atrialfibrillation.com
And finally I landed up in AF ---DOCTORS SYMDROME….THANK YOU for your attention
Professor: define seminar
Student :seminar is defined as process in which one spoils his sleep for one night in an effort to make others sleep.
Thank youDr.P.L.JOHN ISRAELH.O.D OF GENERAL MEDICINE
THANK YOU