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الرجفان االذيني والخطورة الصمية إعداد د عمر القاسم Established Patterns and Severity of Atrial Fibrillation Patterns of Atrial Fibrillation SAF Score* SAF Score Newly Diagnosed AF Paroxysmal: Self-terminating <7d Class 0 Persistent: Sustained ≥7d Permanent: Decision to continue in AF Impact on QOL** Asymptomatic 1 Minimal effect on QOL 2 Minor effect on QOL 3 Moderate effect on QOL 4 Severe effect on QOL ** QOL = quality of life What are the symptoms of atrial fibrillation? Symptoms may be experienced on a regular basis, intermittently or not at all:1,2 Fatigue, palpitations, dizziness, chest pains and breathlessness Many people with atrial fibrillation lack any symptoms:1-3 More than half of episodes of atrial fibrillation are not felt by the patient Atrial fibrillation if present can be diagnosed using an electrocardiogram4 Regular rhythm P wave Irregular rhythm No P wave Asymptomatic atrial fibrillation Asymptomatic atrial fibrillation is a substantial problem for invidual health and for the health care system: it may cause stroke it is frequent despite antiarrhythmic drug therapy or catheter or surgical ablation (it may cause cognitive dysfunction and dementia) Mechanisms of AF Extracardiac Factors: Hypertension Obesity Sleep apnea Hyperthyroidism Alcohol/drugs Atrial Structural Abnormalities: Fibrosis Dilation Ischemia Infiltration Hypertrophy Inflammation Oxidative stress AF Atrial tachycardia remodeling Genetic Variants: Channelopathy Cardiomyopathy RAAS activation Atrial Electrical Abnormalities: ↑Heterogeneity ↓Conduction ↓Action potential duration/refractoriness ↑Automaticity Abnormal intracellular Ca++ handling Autonomic nervous system activation أسباب الرجفان األذيني -1أمراض القلب الرثوية -2أمراض الشرايين التاجية -3ارتفاع ضغط الدم الشرياني -4زيادة نشاط الغدة الدرقية -5عيوب القلب الخلقية -6اإلرتفاع العالي لحرارة الجسم ألي سبب التهاب جرثومي بكتيري أو فيروسي -7التهاب عضلة القلب أوالتهاب غشاء التامور المغلف للقلب -8شرب المسكرات وتعاطي المخدرات -9بعد الجراحات القلبية واحتشاء العضلة القلبية -10غير معروف السبب عند %10من الحاالت . -11األمراض الرئوية المزمنة Risk Stratification in AF Stroke Risk Factors High-Risk Factors Mitral stenosis Prosthetic heart valve History of stroke or TIA Moderate-Risk Factors Age >75 years► Hypertension► Diabetes mellitus► Heart failure or ↓ LV function► Less Validated Risk Factors Age 65–75 years ► Coronary artery disease ► Female gender ► Thyrotoxicosis ► Atrial Fibrillation Morbidity and Mortality 4- to 5-fold increased risk of stroke Doubling of the risk for dementia Tripling of risk for heart failure 40 to 90% increased risk for overall mortality Risk of stroke in AF patients by age group 1.5% in 50 to 59 year age group 23.5% in 80 to 89 year age group Benjamin EJ, et al. Circulation 2009;119:606-618 Priorities in the Management of AF The Patient Care Pathway Rhythm Control Prevention of Thromboembolism Rate Control Overview of AF Management AF Detected Assessment of Thromboembolic Risk (CHADS2) Appropriate Antithrombotic Therapy Detection and Treatment of Precipitating Causes Management of Arrhythmia Rate Control Rhythm Control Strategy of rhythm-control for recent-onset AF/AFL Clear onset <48 h or Therapeutic OAC2 x 3 weeks High-risk patients1 or Onset >48 h or unknown or Inadequate OAC2 Rate-control Hemodynamically unstable Urgent electrical CV at 150-200J Hemodynamically stable Pharmacological or electrical CV at 150-200J Antithrombotic therapy No prior anticoagulation requiredInitiate OAC in ED if CHADS2 >1 or age >65Otherwise, initiate ASA if CAD or vascular d.Early follow-up to review long-term OAC1 High Therapeutic OAC for 3 weeks before CV Trans-esophageal echocardiography (TEE) guided CV3 Antithrombotic therapy Initiate or continue OAC for >4 weeksEarly expert follow-up to review long-term OAC risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/TIA) 2 OAC = oral anticoagulant; N-OAC = Novel OAC (dabigatran, apixaban, rivaroxaban) 3 Immediate N-OAC preferred, but if N-OAC contraindicated use warfarin with heparin bridging If Patient is Hemodynamically Stable Goal is ventricular rate control (<100 bpm) and anticoagulation Resting HR goal should be 60-85 bpm in symptomatic patient Roughly 50% of patients with new onset AF will spontaneously convert to NSR spontaneously within 48 hours of onset Rate control or Rhythm control? AFFIRM trial and RACE trial No survival advantage in terms of stroke prevention rhythm control over rate control rate control Rate control agents Calcium Channel Blockers Beta blockers (caution in patients with reactive airway disease) Digoxin Amiodarone (for patients intolerant or unresponsive to other agents) Indications for Urgent Direct Cardioversion Hemodynamic Instability: Patient with decompensated heart failure Active ischemia: if symptomatic with angina or evidence of ischemia/infarction on EKG Evidence of organ hypoperfusion (altered mental status, cold clammy skin, acute kidney injury) Management of AF in the ED – Recommendations Is Patient Stable? Immediate Risk for Stroke? Low Risk 1. Clear onset <48 hours, or 2. Therapeutic OAC ≥ 3 wks Pharmacological or electrical CV at 150-200 J (Immediate anticoagulation in ED before CV not required) * Antithrombotic therapy Initiate OAC upon discharge from ED (or continue current OAC) if age ≥ 65 or CHADS2 ≥ 1 Otherwise, initiate ASA if CAD or vascular disease Early follow-up to review long-term OAC - YES NO High Risk** No therapeutic OAC ≥ 3 weeks and one of: 1. Onset >48 hours or unknown, or 2. Stroke/TIA <6 months or 3. Mechanical or rheumatic valve disease. Rate-control Therapeutic OAC for 3 Trans-esophageal weeks before echocardiography (TEE) outpatient CV guided CV Antithrombotic therapy - Continue OAC for ≥4 weeks after CV - Early follow-up to review long-term OAC Antithrombotic therapy Unstable – AF causing: 1. Hypotension, or 2. Cardiac ischemia, or 3. Pulmonary edema Consider urgent electrical CV if rate control not effective Antithrombotic therapy - Initiate immediate OAC* in ED Initiate immediate OAC* in ED and and continue for ≥4 weeks continue for ≥4 weeks if any ‘high risk’ ** features present - Early follow-up to review Early follow-up to review long-term OAC long-term OAC a dose of OAC should be given just prior to cardioversion - either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin * Immediate OAC = with bridging to warfarin if a NOAC is contraindicated. Emergency Management of AF Overview of Rate Management Rate Control Drug Choices Heart Failure CAD No Heart Failure or CAD β-blockers ± Digoxin β-blockers* Calcium Channel Blockers# Combination Rx β-blockers* Calcium Channel Blockers# Digoxin† Combination Rx Drugs are listed in alphabetical order *β-blockers preferred in CAD # Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) †Digoxin may be considered as monotherapy only in particularly sedentary individuals Managing Rate Control - Recommended Drugs ß-Blockers Drug Dose Adverse Effects Atenolol 50 - 150 mg p.o. daily bradycardia, hypotension, fatigue, depression Bisoprolol 2.5 - 10 mg p.o. daily as per atenolol Metoprolol 25 mg - 200 mg p.o. bid as per atenolol 20 - 160 mg p.o daily - bid as per atenolol 80 - 240 mg p.o. tid as per atenolol Nadolol Propranolol Calcium Channel Blockers and Digoxin Drug Dose Adverse Effects Verapamil 120 - 480 mg p.o. daily 120 - 240 mg p.o. bid bradycardia, hypotension, constipation Diltiazem 120 - 480 mg p.o. daily 120 - 240 mg p.o. bid bradycardia, hypotension, ankle swelling Digoxin 0.0625 mg - 0.25 mg p.o. daily bradycardia, nausea, vomiting,visual disturbance Overview of Rhythm Management Rhythm Control Choices Normal Systolic Function No Hx of CHF Dronedarone+ Flecainide* Propafenone* Sotalol# Rhythm Control Choices Hx of CHF or Left Ventricular Systolic Dysfunction EF > 35% EF ≤ 35% Amiodarone Sotalol** Amiodarone Catheter Ablation Amiodarone Catheter Ablation Drugs are listed in alphabetical order Dronedarone should be used with caution in combination with digoxin + Class I agents should be AVOIDED in CAD and should be COMBINED • with AV-nodal blocking agents Sotalol should be used with caution in those at risk for torsades de # pointes VT (e.g. female, age > 65 yr, taking diuretics) ** Sotalol should be used with caution with EF 35-40% and those at risk for torsades de pointes VT (e.g. female, age > 65 yr, taking diuretics) What is the link between atrial fibrillation and ? stroke People with atrial fibrillation are five times more likely to have a stroke:1 20-30% of strokes are related to atrial fibrillation2 Up to three million people worldwide have an atrial fibrillation-related stroke every year – that is one person every 12 seconds!3-5 How do you measure the risk of stroke? CHADS2-Score: a simple index that is widely used to assess the risk of stroke of a patient with atrial fibrillation. It can be used to guide antithrombotic therapy Congestive heart failure history - 1 point Hypertension history - 1 point Age > 75 years -1 point Diabetes mellitus history -1 point Stroke or TIA history - 2 points The higher your CHADS2-Score, the higher your risk of having a stroke This score has been expanded in 2010 by additional factors: female gender, age between 65 and 74 years, presence of vascular disease: CHA2DS2VASc 1. Fuster V, Rydén LE, Cannom DS, et al. Circulation 2006; 114:700-52. Stroke risk assessment with CHADS2 and CHA2DS2-VASc Stroke risk assessment with CHADS2 and CHA2DS2-VASc CHADS score % AF popltn 0 low risk 16.3 1 moderate risk 26.7 2(+) high risk 57 Cowan C et al. Heart doi:10.1136/heartjnl-2012-303472 Optimizing Benefit and Reducing Risk Hemorrhage Thrombosis HAS-BLED should be used to identify modifiable risk factors for bleeding Score of ≥3 indicates need for regular clinical review Patients with a higher HAS-BLED score also have a higher CHA2DS2-VASc score There is net clinical benefit in anticoagulating CHA2DS2-VASc >0 whatever HAS-BLED score Antithrombotic Therapy for Atrial Fibrillation Risk Factor No risk factors CHADS2 = 0 One moderate risk factor CHADS2 = 1 Any high risk factor or >1 moderate risk factor CHADS2 >2 or Mitral stenosis Prosthetic valve Recommended Therapy Aspirin, 81-325 mg qd Aspirin, 81-325 mg/d or Warfarin (INR 2.0-3.0, target 2.5) Warfarin (INR 2.0-3.0, target 2.5) Warfarin (INR 2.5-3.5, target 3.0) VKAs have a narrow therapeutic window Adjusted odds ratios for ischaemic stroke and intracranial bleeding in relation to intensity of anticoagulation Odds ratio for event 20 15 10 Ischaemic stroke 5 Target INR Intracranial bleeding 1 1.0 2.0 3.0 4.0 5.0 6.0 International normalized ratio 7.0 8.0 Adapted from Wann et al. Circulation 2011;123;e269-e367 The Ideal Anticoagulant Wide Therapeutic Margin Safe Therapeutic Range Bleeding Thrombosis Thrombosis Dose, Concentration, or Intensity of Anticoagulation The ACTIVE Trial Clopidogrel + Aspirin Atrial Fibrillation + Risk Factors ACTIVE - W Anticoagulation-eligible VKA (INR 2-3) Clopidogrel + Aspirin Open-label Non-inferiority n = 6,706 ACTIVE - A OAC Contraindications or Unwilling Aspirin + Placebo Double-blind Superiority n = 7,554 Irbesartan, 300 mg/d vs. Placebo n = 9,016 Risk Factors: Age 75, hypertension, prior stroke/TIA, LVEF<45%, PAD, age 55-74 + CAD or diabetes Clopidogrel + Aspirin ACTIVE - I Primary outcome: Stroke, systemic embolism, MI or cardiovascular death Antithrombotic Therapy for Atrial Fibrillation Stroke Risk Reductions Warfarin Better Antiplatelet Rx Better All patients Warfarin vs. Aspirin + Clopidogrel Prior OAC VKA-naïve 100% 50% 0 -50% Coagulation pathway TF VKA VII VIIa VKA Initiation IX X Propagatio n VKA Inactive Factor Xa IXa Active Factor Direct Factor Xa inhibition II Rivaroxaban Direct Factor IIa inhibition Prothrombi n IIa Dabigatran Thrombin Fibrinogen Fibrin Transformation Catalysis New Oral Anticoagulants for Stroke Prevention in AF Direct Inhibitors of Factor Xa or Thrombin Comparison of Features of New Oral Anticoagulants in Advanced Stages of Development Rivaroxaban Apixaban Dabigatran Etexilate Target Xa Xa IIa Molecular Weight 436 460 628 Prodrug No No Yes Bioavailability (%) 80 50 6 Time to peak (h) 3 3 2 Half-life (h) 9 9-14 12-17 Renal excretion (%) 65 25 80 None None None Features Antidote Prevention of Stroke in Patients with Chronic Kidney Disease (CKD) – Therapeutic Choices Therapeutic Choices in Patients with Chronic Kidney Disease and Stroke Risk Factors (CHADS2 ≥ 1) GFR Warfarin Dabigatran Rivaroxaban Apixaban GFR ≥ 60 mL/min Dose adjusted for INR 2.0-3.0 150 mg bid or 110 mg bid 20 mg daily 5 mg bid† GFR 50-59 mL/min Dose adjusted for INR 2.0-3.0 150 mg bid or 110 mg bid 20 mg daily 5 mg bid† GFR 30-49 mL/min Dose adjusted for INR 2.0-3.0 150 mg bid or 110 mg bid 15 mg daily GFR 15-29 mL/min (not on dialysis) No RCT Data‡ No RCT Data§ No RCT Data¶ GFR < 15 mL/min (on dialysis) No RCT Data‡ No RCT Data¶ No RCT Data¶ 5 mg bid Consider 2.5 mg bid† 5 mg bid (for GFR > 25 mL/min only) Consider 2.5 mg bid† No RCT Data † Consider Apixaban 2.5 mg po bid if age ≥ 80 and body weight ≤ 60 kg. ‡ Dose adjusted warfarin has been used, but observational data regarding safety and efficacy is conflicting. § Modelling studies suggest that dabigatran 75 mg bid might be safe for patients with GFR 15-29 mL/min, but this has not been validated in a prospective cohort. ¶ No published studies support a dose for this level of renal function; product monographs suggest the drug is contraindicated for this level of renal function. 2 A guidelines based approach to AF management Days of withdrawal prior to high bleeding risk procedure eGFR ml/min/m2 apixaban dabigatran rivaroxaban ≥ 80 2-3 2-3 2-3 50 - 80 2-3 3 2-3 30 - 50 2-3 4 2-3 < 30* 2-3 5 2-3 2014 Focused Update CCS AF Guidelines Can J Cardiol (in press) Percutaneous LAA Occlusion The WATCHMAN® Device Syed T, Halperin JL. Nature Clin Prac Cardiovasc Med 2007; 4:428 Holmes DR, et al. Lancet 2009; 374: 534 Rate vs Rhythm Control for Patients with Symptomatic AF SYMPTOMATIC AF ATTEMPT RATE CONTROL Beta-blocker Calcium channel blocker Special circumstances in which to consider early rhythm control: Highly symptomatic Multiple recurrences Extreme impairment in QOL Arrhythmia-induced cardiomyopathy YES SYMPTOMS RESOLVE NO CONTINUE RATE CONTROL MODIFY RATE CONTROL - CONSIDER RHYTHM CONTROL Paroxysmal AF Low burden recurrence Pill in pocket antiarrhythmic therapy High burden recurrence Maintenance antiarrhythmic therapy Catheter ablation Persistent AF Consider cardioversion Symptoms Symptoms improve, improve, and patient but AF recurs maintains sinus rhythm Symptoms don’t change in sinus rhythm and AF recurs Observe. If AF recurs, determine if symptomatic شكرا ً على إصغائكم شكرا ً على إصغائكم