Download Atrial Fibrillation and Stroke: The Newest Guidelines

Judy R. Walling, RN, MSN, FNP-BC
Nurse Practitioner
MUSC Cardiology
[email protected]
I have no financial disclosures to reveal.

Review of atrial fibrillation (AF)

New treatment guidelines of AF

Anticoagulation and stroke prevention in AF

Medical management of AF

Procedural options of AF
The American Heart
Association estimates that
0.4% of the general
populations have AF.
AF is the most common
clinically significant cardiac
arrhythmia.
The likelihood increases
with age.
Fuster et al. ACC/AHA/ESC 2006 guidelines for the
management of patients with atrial fibrillation. JACC
2006;48:e149-e246.







2.3 million Americans1
4 million by 20301,2
70% of pt with AF are 65-75 yo2
Doubles mortality3
100,000 deaths/year associated with AF4
467,000 hospitalizations/year4
$6-26 billion annual AF related health care
costs
1) Nacarelli GV, et al. Am J Cardiol 2009;104(11):1534-1539.
2012;125(1):e2-e220.
2) Go AS, et al. JAMA 2001;285(18):2370-2375.
Outcomes
3) Miyasaka Y, et al. J Am Coll Cardiol 2007;49(9):986-992.
4) Roger VL, et al. Circulation
5) Kim MH, et al. Circ Cardiovasc Qual
2011;4(3):313-320.
Men are slightly more likely than women to
develop AF but women diagnosed with it carry a
longer-term risk of premature death.
Fuster et al. ACC/AHA/ESC 2006 guidelines for the management of
patients with atrial fibrillation. JACC 2006;48:e149-e246.
There are a number of risk factors that
predispose individuals to the development of
AF. Some of them include….
*Age
*Sleep apnea
*Drugs
*Metastatic disease
*Hyperthyroidism
*Obesity
*Ischemia
AND





Hypertension
Congestive heart failure
Diabetes
Coronary artery disease
Valvular disease
BUT
AF is not life-threatening in and of itself, but it
can lead to other serious medical problems
including:
*Stroke – Your chances
of having a stroke are
five times higher if you
have AF.
*Additional heart rhythm
problems
*Heart failure
Fuster et al. ACC/AHA/ESC 2006 guidelines for the management of
patients with atrial fibrillation. JACC 2006;48:e149-e246.

Decreased quality of life

Increased hospital stays

Increased mortality

Substantial financial burden on health care
system

More AF

24 hours?

48 hours?

Seconds?

Minutes?


Results of the Asymptomatic AF and Stroke Evaluation in
Pacemaker Patients and the AF Reduction Atrial Pacing
Trial (ASSERT) showed that, in this population of
pacemaker patients with hypertension but no history of
atrial fibrillation (AF), episodes of device-detected atrial
tachycardia greater than six minutes were seen in
approximately one-third of patients over almost three
years of mean follow-up.
Further, these arrhythmias were associated with a 2.5-fold
increase in the risk for ischemic stroke and systemic
embolism. In a subgroup of patients with a CHADS2 score
of 2 or higher, device-detected atrial tachyarrhythmias
increased the absolute risk for stroke to 3.78% per year.
"The guidelines attempt to define practices that
meet the needs of most patients in most
circumstances. The ultimate judgment about
care of a particular patient must be made by the
clinician and patient in light of all the
circumstances presented by that patient."
January CT, et al. Circulation 2014;129:000-000
Doi; 10.1161/CIR.0000000000000041
• Shared decision process
• CHA2DS2-VASc (not CHADS2)
• If warfarin, then INR weekly till stable,
then monthly
• If NOAC, then creatinine on initiation
and then at least yearly
• Warfarin for mechanical valves
• Warfarin if CrCl <15 ml/min or on HD
AHA/ACC/HRS Guidelines 2014
Use warfarin if CrCl <15 ml/min (IIa.B)
IIa and Xa inhibitors not recommended in renal
failure with hemodialysis (III-No benefit)
But FDA approved:
Dabigatran 75 mg bid with CrCl 15-30 (modeling)
Rivaroxaban 15 mg qd with CrCl 15-30 (modeling)
Apixaban 5 mg bid with ESRD on HD and no other
risk factors (age ≥80 or weight ≤60 kg) (modeling)
The CHADS2 score is a clinical prediction rule
for estimating the risk of stroke in patients
with non-rheumatic atrial fibrillation (AF), a
common and serious heart arrhythmia
associated with thromboembolic stroke. It is
used to determine whether or not treatment is
required with anticoagulation therapy or
antiplatelet therapy.
CHA2DS2VASc*
0
1
≥2
Valvular
Disease
Recommended Anticoagulation
No therapy
No therapy; warfarin, dabigatran,
rivaroxaban, apixaban
Warfarin, dabigatran, rivaroxaban,
apixaban
Warfarin with INR 2.0-3.5
*CHA2DS2-VASc score for NVAF patients: C = CHF (1 pt) ; H = hypertension (1 pt);
A2 = Age >75 yo (2 pts); D = DM (1 pt); V = Vascular disease (1 pt); A = Age 65-75 yo (1 pt);
S = Female gender (1 pt)
January CT, et al. Circulation 2014;129:000-000.
Doi; 10.1161/CIR.0000000000000041
Warfarin (Coumadin®)
Heparin
Aspirin
Clopidogrel (Plavix®)
Prasugrel (Effient®)
Ticagrelor (Brilinta®)
Dipyridamole (Persantine®)
Enoxaparin (Lovenox®)
Ardeparin (Normiflo®)
Dalteparin (Fragmin®)
Ticlopidine (Ticlid®)
Danaparoid (Orgaran®)
Tinzaparin (Innohep®)
Dabigatran etexilate (Pradaxa®)
Rivaroxaban (Xarelto®)
Apixaban (Eliquis®)
Nonvalvular AF is that which occurs “in the
absence of rheumatic mitral stenosis, a
mechanical or bioprosthetic heart valve, or
mitral-valve repair.”
From Table 4
January CT, et al. Circulation 2014;129:000-000.
Doi; 10.1161/CIR.0000000000000041






Direct thrombin inhibitor
Indications – nonvalvular AF
150mg BID dosing with or without food
- CrCl > 30mL/min
75mg BID dosing with or without food
- CrCl 15-30mL/min
Converting from Coumadin to Pradaxa
- INR < 2.0
Converting from Pradaxa to Coumadin
Based on CrCl and see package insert



Not available in generic AKA dabigatran
When compared to Coumadin, 35% risk
reduction in stroke in relatively health pts,
mean CHADS2 score of 2.2 – statistically
significant (RE-LY and RECOVER trials)
SE’s – bleeding, dyspepsia, gastritis






Factor Xa inhibitor
Indications – nonvalvular AF
20mg once daily with evening meal
- CrCl > 50mL/min
15mg once daily with evening meal
- CrCl 15 to 50mL/min
Converting from Coumadin to Xarelto
- INR < 3.0
Converting from Xarelto to Coumadin
- No trial data available



Not available in generic AKA rivaroxaban
When compared to Coumadin it showed a risk
reduction for stroke that was not statistically
significant but they looked at sicker patients
with a mean CHADS2 score of 2.5 (ROCKET
AF and ARISTOTLE trials)
SE’s – bleeding, thrombocytopenia, elevated
LFTs, pruritis




Factor Xa inhibitor
Indications – nonvalvular AF
Dosing -5mg BID OR
The recommended dose of ELIQUIS is 2.5 mg
twice daily in patients with any 2 of the
following characteristics:
age ≥80 years
body weight ≤60 kg
serum creatinine ≥1.5 mg/dL

Converting from Coumadin to Eliquis

Converting from Eliquis to Coumadin
◦ INR < 2.0
ELIQUIS affects INR, so that initial INR
measurements during the transition to warfarin
may not be useful for determining the appropriate
dose of warfarin. If continuous anticoagulation is
necessary, discontinue ELIQUIS and begin both a
parenteral anticoagulant and warfarin at the time
the next dose of ELIQUIS would have been taken,
discontinuing the parenteral anticoagulant when
INR reaches an acceptable range.



Not available in generic AKA apixaban
When compared to Coumadin with pts with
PAF and persistent AF, it was superior in all
categories – bleeding, stroke risk reduction,
systemic embolism, and lower mortality
(ARISTOTLE and AVERROES trials)
SE’s – bleeding, anemia, nausea
Edoxaban
Factor Xa inhibitor
Once daily dosing
Conclusions :Both once-daily regimens of
edoxaban were noninferior to warfarin with
respect to the prevention of stroke or systemic
embolism and were associated with
significantly lower rates of bleeding and death
from cardiovascular causes. (New England
Journal of Medicine)









ANTICOAGULATION!!!!!
Rate control (AVN blocking drugs)
Cardioversion
Anti-arrhythmic medications (Class I & III)
Catheter ablation
Surgical ablation
Pacemakers (and AV node ablation)
Watchman device
Lariat
Classification
Class I: Interfere with the sodium channel.
Class II: Antisympathetic nervous system
agents. All agents in this class are beta
blocker.
Class III: Affect potassium influx
Class IV: Affect the AV node.
Class V: Work by other or unknown
mechanisms.
Ia: quinidine, procainamide, & dysopyramide
Ib: lidocaine, mexiletine, tocainide, & phenytoin
Ic: encainide, flecainide, moricizine, and
propafenone
II: esmolol, propranolol, & metoprolol
III: amiodarone, azimilide, bretylium, clofilium,
dofetilide, ibutilide, sematilide, dronedarone, &
sotalol
IV: verapamil & diltiazem
V: adenosine & digoxin
The good, the bad, and the ugly






Class IC
Indications - AF, AFL, PSVT, ventricular
arrhythmias
Dosing and titrate to effect
EKG after 6 doses
Available in generic flecainide, propafenone,
and propafenone SR
Contraindicated in pts with CHF and CAD



Addition of Beta Blocker
SE’s from Tambacor – nausea, dizziness,
headache, blurred vision, dyspnea, fatigue
SE’s from Rythmol – chest pain, edema,
palpitation, constipation, nausea, altered
sense of taste, vomiting, dizziness, anxiety,
dyspnea, fatigue






Class III
Indications – atrial arrhythmias and
ventricular arrhythmias
BB and AAD
Dosing and titration – 80mg BID to 160mg
BID
Available in generic sotalol
Hospitalize for doses for initiation




Studies show 80mg BID no better than
placebo
QTc prolongation
Less drug interactions than Tikosyn
SE’s – bradycardia, fatigue, chest pain,
lightheadedness, palpitations, rash, nausea,
headache, dyspnea.




Class III
Indications – ventricular arrhythmias and AF
for pts with heart failure and HOCM.
NOT front tier therapy, ie not FDA approved
for AF pts otherwise.
Should get pts to sign that they are aware
because of risks associated with medication







Dosing and titration
Available in generic amiodarone
Baseline PFTs, LFTs, TFTs, and chest xray
Yearly eye exams
Q6 month LFTs, TFTs, and chest xray
PFTs debatable
BIG concern – pulmonary fibrosis

SE’s – bradyarrhythmias, hypotension,
photodermatitis, photosensitivity, thyroid
dysfunction, constipation, loss of appetite,
nausea, vomiting, increased liver enzymes,
abnormal gait, movement disorders, corneal
deposit, malaise and fatigue






Class III
Indications – AF and AFL
Dosing
Hospitalization for 5 doses to start
medication and titration
Not available in generic AKA dofetilide
Cr q6 mos and EKG q3 mos



Potassium and Magnesium
SE’s – chest pain, dizziness, headache, QTc
prolongation, torsades de pointes, ventricular
arrhythmias
Only approved physicians can prescribe





Class III
Indications – AF, PAF and persistent
Amiodarone derivative
Chemical difference – took out 2 iodines
making drug less toxic and added one side
chain making drug more soluble
Effect – Amio’s half life is 45 days and
Multaq’s half life is 12 hours







Dosing
Not available in generic AKA dronedarone
Can be used with pts with compensated heart
failure but not uncompensated
Spacing of dosing
Take with meals
Liver Tx – 2 out of 600,000
PALLAS study

SE’s – abdominal pain, diarrhea, indigestion,
nausea, vomiting, asthenia, serum creatinine
raised, heart failure, prolonged QTc, liver
failure, CVA
Benefits
- Sinus
rhythm
- Better rate
control
- Pleotropic
effects ?
Risks
- Proarrhythmia
Negative
Benefits
inotropy
Risks
Bradyarrhythmia
- Drug
interactions
- Non-cardiac
toxicity
1) AAD’s should not be used in permanent AF; and 2) Patients on AAD’s
for paroxysmal or
Implications:
persistent AF should be followed regularly for development of persistent AF and AAD stopped if reestablishment of sinus rhythm not planned.






Cardioversion
Pacemakers and AV node ablation
Catheter ablation
Surgical ablation
Watchman device
Lariat

Do pacemakers treat AF?

How are pacemakers used for AF patients?

AV Node Ablation is a procedure by which the heart's AV
node (Atrioventricular node, the electrical pathway that
connects the top chambers to the bottom chambers of the
heart) is modified to restore normal heart rhythms. The
procedure involves cauterizing or freezing the AV node to
block or alter electrical conduction through this region of
the heart. During a typical AV node ablation, a permanent
pacemaker is implanted in the chest to mechanically
regulate the pulse rate in the lower chambers of the heart
(ventricles) to match the natural pulse rate in the upper
chambers of the heart (atria).
No Structural Heart
Disease
Dofetilide
Dronedarone
Flecainide
Propafenone
Sotalol
Catheter
Ablation
Structural Heart
Disease
CAD
Dofetilide
Catheter
Dronedarone
Ablation
Heart Failure
Amiodarone
Dofetilide
Sotalol
Amiodarone
Amiodarone
January CT, et al. Circulation 2014;129:000-000.
Doi; 10.1161/CIR.0000000000000041



Patient with non-valvular AF
CHADS2 score of 2 or higher
Absolute or relative contraindication to long
term oral anticoagulation therapy (OAT)
◦
◦
◦
◦
Intolerance to OAT
Recurrent GI Bleed
Hemorrhagic CVA
Embolic CVA on therapeutic OAT

Amplatzer Plug (Watchman)
◦ Must be able to take Coumadin for 6 weeks post
procedure
◦ Placement of flexible braided
nitinol mesh
◦ Catheter-based delivery
◦ Lifetime/permanent

LARIAT
◦ Suture closure, catheter-based
◦ CTA Heart pre-procedure to assess LAA anatomy
 Specifically looking at size, shape, positioning
 Assess for LAA thrombus
 If LAA is >40 mm, tucked behind PA, or oddly shaped
cannot/difficult to place.
 Cannot place if LAA thrombus is present
 Can attempt to dissolve with OAT

LARIAT
◦ Does not require pre or post procedure OAT
◦ No prior sternotomy
 Advancing epicardial sheath difficult due to adhesions
◦ No prior pericarditis
-
-
-
AF is the most common clinically significant
cardiac arrhythmia.
Stroke prevention is the primary concern in
treatment of AF.
There are increasing options for oral
anticoagulation; however, the new guidelines
clearly recognize that the choice should be a
shared decision process.
Ablation is now considered front line treatment
in some patients with AF.
Left atrial appendage closure devices are an
excellent option for patients who cannot tolerate
oral anticoagulation.