Transcript Management Principles of AF

Practical Rate and Rhythm Management
of Atrial Fibrillation
New Paradigm in Managing Atrial
Fibrillation: A Campaign to Promote
Optimal Patient Care
Slide set developed by:
Michael C. Delaughter, MD, PHD: EP-Cardiology PA
Michael Eifling, MD: Texas Heart Institute at St. Luke’s Episcopal Hospital and Baylor University
Rohit Mehta, MD: Sanger Heart and Vascular Institute
Management Principles of AF
Therapeutic Goals
Cornerstones of AF Management
Rate Control
Rhythm Control
Anticoagulation
Control of symptoms
Control of symptoms
Prevention of
thromboembolism
Treatment or prevention
of Tachycardia Induced
Cardiomyopathy (CMP)
Reduction in
Hospitalizations
Minimization of
bleeding risk
Reduction in
Hospitalizations
2
www.HRSonline.org
Rate versus Rhythm Control for AF
 The AFFIRM, RACE and AF-CHF trials have shown no
mortality benefit from a rhythm control strategy compared to a
rate control strategy.
 Therefore, a rate control strategy, without attempts at
restoration or maintenance of sinus rhythm (SR), is reasonable
in some patients with AF, especially those who are elderly and
asymptomatic.
 If rate control offers inadequate symptomatic relief, restoration
of SR may become a long-term goal.
 Restoration and maintenance of SR continues to be a
reasonable treatment approach in many patients with AF.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
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Ventricular Rate Control
Principles of a Rate Control Strategy:

Adequate control of the ventricular response during AF can significantly improve
symptoms and is critical to avoid tachycardia-mediated cardiomyopathy.

Most patients managed using a rhythm control strategy also require medications for
rate control.

Rate control during atrial flutter tends to be more difficult than during AF.
What is Adequate Rate Control?

Control of the ventricular rate during AF is important both at rest and with exertion.

No standard method for assessment of heart rate control has been established.

Criteria for rate control vary with patient age but usually involve achieving ventricular
rates between 60 and 80 bpm at rest and between 90 and 115 bpm during moderate
exercise.

For the AFFIRM trial, adequate control was defined as an average HR up to 80 bpm at
rest and either an average rate up to 100 bpm during Holter monitoring with no rate
above 100% of the maximum age-adjusted predicted exercise HR, or a maximum HR
of 110 bpm during a 6-min walk test.

In the RACE trial, rate control was defined as less than 100 bpm at rest.

Only about 5%of patients from these trials required AV ablation to achieve HR control.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
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www.HRSonline.org
Ventricular Rate Control:
Drugs to Control the Ventricular Response
 Beta blockers are the most effective drug class for rate control.
 Calcium channel antagonists (nondihydropyridine) are good
choices for patients with asthma or COPD requiring beta
agonist inhaler therapy.
 Digoxin provides relatively poor rate control during exertion and
should be reserved for patients with systolic HF.
 Digoxin does not convert AF to SR and may perpetuate AF.
 Digoxin is marginally effective as a sole agent, but may prove
useful in combination with beta blocker or calcium channel
antagonists, particularly in hypotensive patients.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. with modifications.
5
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Ventricular Rate Control:
Drugs to Control the Ventricular Response
 A combination of a beta blocker and either a calcium channel
antagonist or digoxin may be needed to control the HR.
 The choice of medication should be individualized and the dose
modulated to avoid bradycardia.
 Beta blockers and calcium channel antagonists should be used
cautiously in patients with HF.
 AV nodal blocking drugs at doses required to control the
ventricular response can cause symptomatic bradycardia that
requires pacemaker therapy.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
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www.HRSonline.org
Ventricular Rate Control:
Drugs to Control the Ventricular Response
 Some antiarrhythmic drugs that are used to maintain sinus
rhythm, such as sotalol, dronedarone, and amiodarone, also
provide some control of the ventricular response when patients
are in AF.
 Amiodarone should rarely be used for rate control because of
its potential for toxicity.
 IV digoxin or nondihydropyridine calcium channel antagonists
given to patients with AF and WPW may accelerate the
ventricular response and are not recommended.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
7
www.HRSonline.org
Ventricular Rate Control:
AV Nodal Ablation
 Ablation of the AV conduction system and permanent pacing
(the “ablate and pace” strategy) is an option for patients who
have rapid ventricular rates despite maximum medical therapy
and often yields remarkable symptomatic relief.
 There is growing concern about the negative effects of longterm RV pacing.
 Biventricular pacing, on the other hand, may overcome many of
the adverse hemodynamic effects associated with RV pacing
and is preferred when systolic dysfunction is present.
 Catheter ablation of the AV node should not be attempted
without a prior trial of medication to control the rate.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed. with modifications.
8
www.HRSonline.org
CHADS2 Risk Stratification Scheme
Risk Factors
Score
C
Recent congestive heart failure
1
H
Hypertension
1
A
Age 75 years
1
D
Diabetes mellitus
1
S2 History of stroke or transient ischemic
attack
2
Rockson et al. J Am Coll Cardiol. 2004;43:929-935.
www.HRSonline.org
Maintenance of Sinus Rhythm:
Principles of Antiarrhythmic Drug Therapy
 AF is a chronic disorder and is likely to recur in most patients without
antiarrhythmic drugs (AADs).
 Pharmacological therapy is indicated in patients who can tolerate
AADs and who have a reasonable chance to maintain sinus rhythm.
 Pharmacological therapy is indicated to suppress symptoms, improve
exercise capacity, improve hemodynamic function, and prevent
tachycardia-induced cardiomyopathy.
 The risk of stroke may not be reduced by suppression of AF.
 Before administering an antiarrhythmic drug, precipitants of AF such
as hypertension, valve disease, CHF, hyperthyroidism, and OSA
should be identified and corrected.
 Antiarrhythmic drug (AAD) choice is based on side-effect profiles and
presence of structural heart disease, heart failure, or hypertension.
 Drug choice should be individualized and account for underlying renal
and hepatic function.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
www.HRSonline.org
Maintenance of Sinus Rhythm:
Principles of Antiarrhythmic Drug Therapy
 Drugs should be used to decrease the frequency and duration of
episodes, and to improve symptoms.
 AF recurrence without symptoms is not indicative of treatment failure
and does not necessitate a change in AAD therapy.
 An AAD should be abandoned when it does not result in symptomatic
improvement or causes adverse events.
 Ensure normal electrolyte status and appropriate anticoagulation prior
to starting antiarrhythmic drug therapy.
 Initiate AV nodal blockade prior to the use of antiarrhythmics such as
flecainide that do not provide substantial AV node blockade.
 Initiate therapy at a low dose and titrate up as needed and after
evaluating drug effects on ECG parameters.
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
www.HRSonline.org
ACC/AHA/ESC Guidelines
Maintenance of Sinus Rhythm in Specific Patient Populations
Maintenance of Sinus Rhythm
No (or minimal)
Heart Disease
Hypertension
Coronary Artery
Disease
Heart Failure
Substantial LVH
Flecainide
Propafenone
Sotalol
Amiodarone Catheter
Dofetilide
Ablation
No
Yes
Flecainide
Propafenone
Sotalol
Amiodarone
Amiodarone Catheter
Ablation
Dofetilide
Catheter
Ablation
Dofetilide
Sotalol
Amiodarone
Amiodarone
Dofetilide
Catheter
Ablation
Calkins et al. HeartRhythm 2007 HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46
www.HRSonline.org
Catheter
Ablation
12
Maintenance of Sinus Rhythm in Specific Patient Populations
Suggested Scheme Including Dronedarone
Maintenance of Sinus Rhythm
No (or minimal)
Heart Disease
Hypertension
Coronary Artery
Disease
Heart Failure
Dofetilide
Sotalol
Dronedarone
Amiodarone
Dofetilide
Substantial LVH
Flecainide
Propafenone
Sotalol
Dronedarone
No
Flecainide
Propafenone
Sotalol
Dronedarone
Yes
Amiodarone
Dronedarone
Amiodarone Catheter
Dofetilide
Ablation
Amiodarone Catheter
Ablation
Dofetilide
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Catheter
Ablation
Amiodarone
Catheter
Ablation
Abbreviation: LVH, left ventricular hypertrophy.
Modified from Fuster, V. et al. J. Am. Coll. Cardiol. 48, e149–e246 (2006).
Catheter
Ablation
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Rationale for Initial Trial of Medical Therapy
 The relative safety and efficacy of ablation vs. antiarrhythmic drugs has
not been firmly established but large randomized trials are ongoing
 Ablation:
– Complication rate: 5.9%
– Single-procedure success rate without AADs: 57%
– Multiple-procedure success rate without AADs: 71%
– Multiple-procedure success rate with AADs: 77%
 AAD Therapy:
– Adverse event rate: 30% (common but less severe)
– Success rate: 52%
Calkins et al. CircEP. 2009;2:349-361.
www.HRSonline.org
Atrial Fibrillation Ablation Candidates
 Symptomatic Paroxysmal or Persistent Atrial Fibrillation
 Second-line Therapy
– Failure of Class IC or Class III agent
– Intolerance to Medical Therapy, Refusal of Medical Therapy
 Other Considerations:
– Young patients with paroxysmal atrial fibrillation, in whom
decades-long drug therapy is undesirable
– Congestive Heart Failure due to tachycardia-induced
cardiomyopathy, in whom drug choices are limited by the
presence of CHF
www.HRSonline.org
Atrial Fibrillation Ablation Candidates
 Limitations in Efficacy
– Longstanding Persistent Atrial Fibrillation (>1 year)
– Enlarged LA (>55 mm)
– Age > 70 years
 Left atrial or Left atrial appendage thrombus is an absolute
contraindication to atrial fibrillation ablation.
Calkins et al. HeartRhythm 2007 HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46
www.HRSonline.org
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Atrial Fibrillation Ablation Outcomes
 Definition of success includes:
– Freedom from symptomatic atrial fibrillation
– Freedom from all atrial fibrillation
– Facilitation of antiarrhythmic therapy
– Eradication of anticoagulant therapy
 Duration of Success:
– Freedom from atrial fibrillation at one year
– Freedom from late atrial fibrillation
– Most common accepted success definition
– Freedom from atrial fibrillation off antiarrhythmic therapy at one
year
– Late recurrences: greater than 12 months
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46
www.HRSonline.org
Atrial Fibrillation Ablation Outcomes
 Blanking period of 2 months post ablation
– Early recurrence of AF events termed “early events”
 Minimum of symptomatic monitoring
– Suggested asymptomatic surveillance at 6 month intervals
– 30 day auto-triggered monitors
– Symptom triggered event monitors with weekly asymptomatic
transmissions
– 24-72 hour Holter monitoring.
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46
www.HRSonline.org
Atrial Fibrillation Ablation Outcomes
 Paroyxsmal
– 70-80% success at freedom from atrial fibrillation at one year off
anti-arrhythmic therapy.
– 30% of patients required 2 procedures to achieve this result.
– Most utilized pure-pulmonary vein isolation approach
 Persistent
– Similar success rates in persistent patients with similar end-point
and need for repeat procedure
– More commonly requires substrate modification (targeting of
CFAE) and linear ablation
 Long-Standing Persistent
– Utilizing stepwise approach (PV isolation Linear ablation
CFAE), some studies have demonstrated 70-80% freedom from
atrial fibrillation at one year off anti-arrhythmic therapy
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46
www.HRSonline.org
Atrial Fibrillation Ablation Outcomes
 Randomized Trials:
– Paroxysmal Atrial Fibrillation (Flecainide or Sotalol vs Ablation)
 One year freedom from atrial fibrillation (AF)
 37% freedom from AF in anti-arrhythmic arm
 87% freedom from AF in ablation arm
– Persistent Atrial Fibrillation (Ablation vs. Cardioversion)
 One year freedom from AF or atrial flutter
 74% freedom from AF in ablation arm
 58% freedom from AF in cardioversion arm
Calkins et al. HeartRhythm 2007; HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation; 4: 1-46
www.HRSonline.org
Atrial Fibrillation Ablation Outcomes
 Randomized Trials:
– Paroxysmal or Persistent Atrial Fibrillation
 One year freedom from AF (ablation vs. anti-arrhythmic (AA)
drug)
 9% freedom from AF in the AA arm
 56% freedom from AF in the ablation arm
– Paroxysmal Atrial Fibrillation
 One year freedom from AF (ablation vs anti-arrhythmic (AA)
drug)
 22% freedom from AF in AA arm
 86% freedom from AF in ablation arm
Stabile et al. European Heart Journal 2006; 27: 216-221
www.HRSonline.org
Atrial Fibrillation Ablation Outcomes
 Paroxysmal Atrial Fibrillation
– One year freedom from AF (ablation vs anti-arrhythmic (AA) drug)
– 22% freedom from AF in AA arm
– 86% freedom from AF in ablation arm
 Paroxysmal and Persistent Atrial Fibrillation
– One year freedom from AF (ablation vs. anti-arrhythmic (AA) drug)
– 7% freedom from AF in AA arm
– 75% freedom from AF in ablation arm
– 63% of AA treated patients crossed over
Stabile et al. European Heart Journal 2006; 27: 216-221
www.HRSonline.org
Final Summary for AF Ablation



Identifying appropriate ablation candidates

Failing medical therapy

Refusing medical therapy

Need for symptoms

Young patients
Differences in approach for paroxysmal and persistent patients

Lesion set

Utility of isuprel post ablation

Likelihood of recurrence / need for additional procedures (see Cappato, Circulation, AF registry
outcomes paper)

Definition of success / likelihood of success

Managing atypical flutter / need for confirmation of block across lines
Surgical based ablation

Relative efficacy vs. catheter based

Rationale / benefit of appendage ligation / resection

Cox III – the “gold standard”

Efficacy of other lesion sets, modalities (bipolar RF, cryo, HIFU) vs. Cox
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