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Atrial Fibrillation Rate vs Rhythm control Which is better ? Dwayne Campbell, MD Disclosure • • • • Medtronic Milestone Pharmaceuticals, Inc. National Institutes of Health Employee-Iowa Heart Center/Mercy-Des Moines Objective • Review goals of Atrial fibrillation management • Compare rate vs rhythm control management Strategy in achieving those goals • Review current guidelines for afib management Epidemiology and Prognosis • Most common arrhythmia • >80% of individuals are > 65yo • 1/3 of hospitalizations for arrhythmias • 2.3 million people in North America • 70,000 strokes/yr due to AF • 1990 – 2005 admissions increased 66% • $1 billion spent yearly on postop AF JACC 2004; 43:1001-1003 Mortality and AF Am J Cardiol 2001; 87:346 Classification • Paroxysmal • • • Spontaneous termination Last < 7 days Usually < 48 hrs • Persistent • • No spontaneous termination Lasting > 7 days • Long- Standing persistent • >12 months • Non valvular • >AF in the absence of rheumatic mitral stenosis, a mechanical or bio prosthetic heart valve, or mitral valve repair Management strategy • Rate control – HR control with no commitment to restore NSR • Drugs or pacer • Rhythm control • Attempt restoration and maintenance of NSR • cardioversion or catheter ablation • Both strategies require anticoagulation to prevent thromboembolism CHA2DS2-VASc Score Risk factor Score Congestive heart failure/LV 1 Hypertension 1 Age ≥75 years 2 Diabetes mellitus 1 Stroke/TIA/thromboembolism 2 Vascular disease 1 Age 65-74 years 1 Sex category (ie, female sex) 1 Maximum score 9 * Prior MI, PAD, aortic plaque. Actual rates of stroke in contemporary cohorts may vary from these estimates Camm AJ et al: Eur Heart J 2010;31:2369-2429 Ultimate Goal of Management • Improve Mortality /Morbidity • Decrease incidence of of Thromboembolic events • Improve quality of life •4060 patients - randomized to rate or rhythm control strategies •Digoxin, calcium channel blocker, and/or beta-blocker were used for rate control(2027 patients) •Electrical cardioversions, class IA, IC, and III drugs to rhythm-control arm (2033 ) •Oral anticoagulation adjusted to maintain INR of 2.0 to 3.0 •Could be stopped if sinus rhythm > 4 weeks AFFIRM Trial P 0.08 Major trials comparing rhythm to rate controls • PIAF-Pharmacological Intervention in Atrial Fibrillation (2000) • STAF - Strategies of Treatment of Atrial Fibrillation study(2003) • RACE-Rate Control vs Electrical cardioversion for persistent AF(2002) • AFFIRM-AF follow–up investigation of rhythm management (2002) • HOT CAFÉ- - How to Treat Chronic Atrial Fibrillation(2004) • AF CHF-Atrial Fibrillation and Congestive Heart Failure(2007) • J RHYTHM- Japanese Rhythm Management Trial for AF(2009) Mortality de Denus et al. Arch intern Med. 2005;185:258 Thomboembolic Events de Denus et al. Arch intern Med. 2005;185:258 Quality of Life Measures Singh et al. J Am Coll Cardiol 2008;48:721-30 “Nature has equipped the human heart with a complex electrical system for the purpose of coordinated propulsion of blood under a variety of physiologic conditions. Considerable effort is expended by the heart to maintain sinus rhythm. Cardiac electrophysiologists…are frustrated by the conundrum that atrial fibrillation is associated with increased morbidity and mortality, yet attempts to prove that a strategy to maintain nature’s rhythm has a favorable effect on patients have been met with one setback after another. Cain ME. Rhythm control in atrial fibrillation—one setback after another New Engl J Med. 2008;258-2725- So why no difference between strategies ? • limitations of anti-arrhythmic drugs • all proarrythmic(increase mortality with SHD • end organ toxicity • poor long term efficacy • treatment palliative not curative • subjective adverse events • limitations of the trials Major trials comparing rhythm to rate controls Rhythm controlled preferred • Persistent symptoms despite rate controls • Inability to maintain adequate rate controls • First episode of atrial fibrillation • Younger patients • Sign symptoms of left ventricular dysfunction • Patient preference 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation Rhythm Control Strategy . T. January et al. Circulation. 2014;130:e199-e267 Craig PAF – 198 patients JACC 2006; 48 (11):2340-2347 Rate control preferred • AF duration > one year • Increased left atrial size>4.5cm • Underlying cause of AF that has not been treated • Age >65y • Patient preference 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation Rate control strategy Craig T. January et al. Circulation. 2014;130:e199-e267 . Adequate rate control HR<110 at rest Conclusion • Due to limitation of current medical therapy a rate control strategy has not been shown to be inferior to a rhythm control strategy • Unclear what is the best option is for younger patients • Ablation is more effective in maintaining NSR than AAD but Data on whether or not this translates to improved mortality is Pending (CABANA Trial) Management • • • • Rate control Prevention of thromboembolism Conversion to NSR – always try Management – Pattern of presentation – persistent, paroxysmal, permanent • Underlying conditions • Restoration and maintenance of NSR • HR control and anticoagulation Kaplan-Meier estimates of the cumulative incidence of the primary outcome (composite of: death from cardiovascular causes, hospitalization for heart failure, and stroke, systemic embolism, bleeding, and life-threatening arrhythmic events) comparing strict versus lenient rate control Who Gets AF? • Both genders get AF but it is more dangerous for women • Men with AF have 1.5 times greater risk of death than men without AF • Women with AF have 1.9 x greater risk of death than women without AF • Structural heart disease, age, DM, CHF, HTN, OSA, COPD, TSH, familial, CAD Circulation 1998; 98 (10): 946-52 Impact of OSA on Atrial Fibrillation Atrial Fibrillation Definition • Atrial fibrillation (AF) is an atrial tachyarrhythmia • Uncoordinated atrial activation with lack of atrial mechanical function • AF impulses usually generate in the atria and in the pulmonary veins