Download Difficult Cases in Atrial Fibrillation

Difficult Cases in
Atrial Fibrillation
Ascot Cardiology GP Symposium
April 2014
Atrial Fibrillation
§  1-2% general population
§  40-50yrs <0.5%, 80yrs 5-15%
§  Death-rate doubled
§  Stroke-risk – 5x increased (and severity
increased)
§  Can be ‘silent’
§  Non-pharmacalogical interventions developed
Atrial Fibrillation - Nomenclature
§ 
1st diagnosed AF
§ 
Paroxysmal AF – self-terminating
§ 
Persistent AF - >7days or required cardioversion
§ 
Long-standing persistent AF - >1-year with rhythm control
§ 
Permanent AF – acceptance of rhythm
§ 
Silent AF – diagnosed opportunistic or from complications
Atrial Fibrillation Difficult Cases!!
§  Diagnosis
§  Underlying cause/concomitant cardiovascular
disease
§  Symptom management
§  Thromboembolism prevention
§  Rate / Rhythm control
Case One
60 yr male with known AF
Case One
60 yr male with known AF
§  PAF that became permanent 2007
§  HTN
§  Initial reduced LV function
§  Warfarin, Cilazapril 2.5mg od, Diltiazem
360mg od and Metoprolol 47.5mg od
§  Asymptomatic
§  Echo now shows low-normal LV function
Vote Now
Case One – Question One
60 yr male with known AF
What should be the thromboembolism management?
1. Leave on Warfarin
45%
2. Change Warfarin to Dabigatran
53%
3. Change Warfarin to Aspirin
0%
4. Stop Warfarin
2%
10
Vote Now
Case One – Question Two
60 yr male with known AF
Rate/Rhythm Control
1. Leave on current doses of Diltiazem/Metoprolol
79%
2. Stop Metoprolol
8%
3. Stop Diltiazem
5%
4. More tests
9%
10
Case One - Management
60 yr male with known asymptomatic AF
§  Left on Warfarin
§  Holter monitor – good AF rate control
§  Alcohol reduction
Case One - Management
60 yr male with known asymptomatic AF
§  March 2012 – lifting and shoulder ‘popped’
§  Admitted with right shoulder haemarthrosis
§  INR 4.1
§  Treated with analgesia and Warfarin changed to
Aspirin (declines Dabigatran)
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Thromboembolic Risk Assessment
•  In assessing risk of stroke in a patient with
nonvalvular AF usage of the CHA2DS2-VASc
recommended
•  History of stroke or transient ischemic attack,
or a CHA2DS2-VASc score ≥2, oral
anticoagulation is recommended
•  CHA2DS2-VASc score of 1: no antithrombotic
therapy, oral anticoagulation, or aspirin
•  CHA2DS2-VASc score of 0, it is reasonable to
omit antithrombotic therapy
Assessment of Stroke Risk – CHA2DS2VASc
Assessment of Bleeding Risk - HASBLED
Assessment of Bleeding Risk - HASBLED
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Case One - Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Case One - Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Assessment of Stroke and Bleeding Risk
American College of Cardiology SPARC tool
Case Two
50yr male – exercise-induced palpitations
Vote Now
Case Two – Question One
50yr male – exercise-induced palpitations
What investigation?
1. Nil
0%
2. Holter monitor
16%
3. Event recorder
10%
4. Exercise test
63%
5. ECG with symptoms
11%
10
Case Two
50yr male – exercise-induced palpitations
Vote Now
Case Two – Question Two
50yr male – exercise-induced palpitations
What drug treatment should be started?
1. Metoprolol/Bisoprolol
30%
2. Diltiazem/Verapamil
23%
3. Sotalol
23%
4. Flecainide
18%
5. Amiodarone
7%
10
Case Two
50yr male – exercise-induced palpitations
Vote Now
Case Two – Question Three
50yr male – recurrent exercise-induced palpitations
What next?
1. Persist with Flecainide
7%
2. Change to Sotalol
11%
3. Change to Amiodarone
8%
4. Ablation
74%
10
Case Two
50yr male – exercise-induced palpitations
§ 
Underwent atrial fibrillation ablation (pulmonary venous
isolation)
In lone atrial fibrillation and a normal left atrial size,
§ 
§ 
§ 
80% chance of a good result over five years (20 – 30% chance
of requiring more than one procedure)
4-6% risk of complications (stroke, pulmonary veins stenosis,
phrenic nerve injury, mitral valve injury, pericardial bleeding
requiring drainage, emergency cardiac surgery, esophageal
injury,
Small but extremely serious risk of atrial esophageal fistula and
death (1:1000).
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Rhythm Control
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Catheter Ablation of Atrial Fibrillation
§  Catheter ablation is useful in patients with
symptomatic, paroxysmal AF who have not
responded to or tolerated antiarrhythmic
medications (Class I)
§  Catheter ablation is also reasonable in
selected patients with symptomatic,
paroxysmal AF prior to a trial of medical
therapy, provided that it can be performed at
an experienced center (Class IIa)
Case Three
60yr male – AF with heart failure
•  2007
HTN. OSA intolerant of CPAP. Moderate+ alcohol intake
Echo – LVH with diastolic dysfunction
•  2011 April SOB and CCF
AF120bpm
Echo – moderate LV impairment (EF 35%) LA mildmoderately enlarged.
Mild renal impairment
Vote Now
Case Three – Question One
60yr male – AF with heart failure
Best initial management?
1. Rate-control
48%
2. Rhythm-control
26%
3. Angiography
0%
4. Anticoagulation
26%
5. Aspirin only
0%
10
Vote Now
Case Three – Question Two
60yr male – AF with heart failure.
Most appropriate medication(s) for rhythm/rate control?
1. Diltiazem/Verapamil
32%
2. Metoprolol/Bisoprolol
48%
3. Amiodarone
2%
4. Digoxin
11%
5. Sotalol
6%
10
Vote Now
Case Three – Question Three
60yr male – AF with heart failure.
How is rhythm control best managed
1. Cardiovert with medication (Flecainide/Sotalol/Amiodarone)
32%
2. Cardiovert electrically ASAP
13%
3. Cardiovert electrically ASAP with transoesophageal echo
9%
4. Cardiovert after anticoagulated for 3 weeks
32%
5. Cardioversion likely futile
15%
10
Case Three
60yr male – AF with heart failure.
• 
• 
• 
• 
• 
• 
• 
Cardioverted electrically ASAP with transoesophageal
echo
Post-CV echo showed moderate-severe LV impairment
EF 30%
Coronary angiography – mild disease
Repeat echo 3 weeks after CV – low-normal LV function
Repeat echo 8 weeks after CV –normal LV function
Amiodarone maintained until November
INRs erratic
Case Three
60yr male – AF with heart failure.
• 
• 
• 
• 
Jan 2012 – SOBOE
April 2012 – AF 130bpm, EF 35%
Rx Amiodarone, Dabigatran – planned CV
May 2012 – admitted ACH – IV diuresis and
CV. D/c Frusemide, Amiodarone, Diltiazem,
Dabigatran and Candesartan
Case Three
§  60yr male – AF with heart failure.
Vote Now
Case Three – Question Four
60yr male – AF with heart failure.
What is the next best management strategy?
1. Rate control on Dabigatran
26%
2. Rate control on Warfarin
6%
3. Further DC cardioversion on Amiodarone
18%
4. Ablation therapy
50%
10
Case Three
60yr male – AF with heart failure.
§  July 2012 TOE-guided CV
§  EF 20-25%
§  Aug 2012 Back in AF
§  EF 20%, LA moderately enlarged
§  Late Aug 2012 – Back in SR!!! Referred CPAP
§  Sep 2012 EF 35%
§  Oct 2012 EF 45-50%
Case Three
60yr male – AF with heart failure.
Dec 2012 Auckland City Hospital
§  Thoracoscopic AF ablation
§  Complicated by bleeding – converted to thoracotomy
§  Prolonged ventilation
Feb 2014
§  SR maintained, EF normalised
§  Off Amiodarone
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Rhythm Control
•  Most patients enrolled in trials of AF catheter
ablation have generally been younger, healthy
individuals with symptomatic paroxysmal AF
refractory to ≥1 antiarrhythmic medication.
•  The safety and efficacy of catheter ablation are
less well established for other populations of
patients, especially patients with longstanding
persistent AF, very elderly patients, and patients
with significant HF including tachycardia-induced
cardiomyopathy
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Rhythm Control
dcz0689
Rate
PR
QRSD
QT
QTc
21-Aug-2007 14:13:13
172
120
68
253
428
diane rose
Middlemore Hosp.
Case Four
No interpretive report, criteria version not available
EMGCARE
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
Axis
P
Ind.
QRS
18
T
81
Requested by:
Edited
PRELIMINARY-MD MUST REVIEW
I
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
II
02156 25.0 mm/s 10.0 mm/mV ~ 0.05 Hz - 100 Hz HP
Vote Now
Case Four – Question One
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
What is the best initial management?
1. Diltiazem or digoxin for rate control
66%
2. Metoprolol for rate control
9%
3. Amiodarone for rhythm control
13%
4. Flecanide for rhythm control
3%
5. Sotalol for rhythm control
9%
10
Case Four
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
§  SOB worse. No palpitations.
§  ECG – sinus rhythm
§  Echo - normal LV/RV function, mild LA dilatation
§  Sotalol stopped. Diltiazem and aspirin started.
dcz0689
Rate
PR
QRSD
QT
QTc
06-Nov-2007 13:13:32
184
126
85
241
422
Case Four
Middlemore Hosp.
No interpretive report, criteria version not available
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
§  3 months later– admitted SOB
EMGCARE
Axis
P
Ind.
QRS
16
T
90
Requested by:
Edited
PRELIMINARY-MD MUST REVIEW
I
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
II
02156 25.0 mm/s 10.0 mm/mV ~ 0.05 Hz - 100 Hz HP7
0290
Vote Now
Case Four – Question Two
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
1. Rate control with Metoprolol
2%
2. Rate/rhythm control with Amiodarone
31%
3. Rate control with Digoxin
21%
4. Electively cardiovert (on anticoagulation)
46%
10
Case Four – Betablockers in COPD
66yr female – Aug 2007 advanced COPD, smoker, hypercholesterolaemia,
HTN
Cardioselective β-blockers (safe)
Atenolol, Celiprolol, Metoprolol
Non-cardioselective β-blockers (not safe)
Carvedilol, Labetolol, Nadalol, Pindolol, Propanolol, Sotalol, Timolol
DO NOT USE
1. Patients with poorly controlled asthma
2. Patients with severe asthma who require continuous or frequent oral
steroids
3. Patients with severe COPD (FEV1 < 40% predicted)
4. Patients with an exacerbation of their airways disease
Vote Now
Case Four – Question Three
66yr female – advanced COPD, smoker, hypercholesterolaemia,
HTN
TOE-guided CV – SR for 20 minutes
What should be the next step?
1. CV on Amiodarone
0%
2. Rhythm control on Diltiazem/Digoxin
46%
3. Rhythm control on Amiodarone
6%
4. Ablation therapy
46%
5. Other
3%
10
dcz0689
Rate
PR
QRSD
QT
QTc
19-Mar-2008 12:13:33
70
204
147
453
489
Middlemore Hosp.
Case Four
No interpretive report, criteria version not available
EMGCARE
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
Axis
P
Ind.
QRS
168
T
-86
Requested by:
Edited
PRELIMINARY-MD MUST REVIEW
I
aVR
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
II
02156 25.0 mm/s 10.0 mm/mV F ~ 0.50 Hz - 100 Hz W HP7
39375
Vote Now
Case Four – Question Four
66yr female – advanced COPD, smoker,
hypercholesterolaemia, HTN
What rhythm does the ECG show?
1. Sinus rhythm
2%
2. Ventricular paced
11%
3. Atrial fibrillation
0%
4. Atrial fibrillation with ventricular pacing
81%
5. Complete heart block
6%
10
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Rate Control
•  A heart rate control (resting heart rate <80 bpm) strategy
is reasonable for symptomatic management of AF
•  In patients who experience AF-related symptoms during
activity, the adequacy of heart rate control should be
assessed during exertion
•  AV nodal ablation with permanent ventricular pacing is
reasonable to control the heart rate when pharmacological
therapy is inadequate and rhythm control is not achievable
•  Oral amiodarone may be useful for ventricular rate control
when other measures are unsuccessful or contraindicated
2014 AHA/ACC/HRS Atrial Fibrillation Guideline
Rate Control
Atrial Fibrillation Management
SESSION 3: Interactive Case Studies
Vote Now Complex Atrial Fibrillation
Dr Selwyn Wong How relevant and useful did you find the session? 65% 29% 2% 4% 1 2 3 4 Poor Average Good Excellent 10 Vote Now Complex Atrial Fibrillation
Dr Selwyn Wong Was the material presented in a balanced way? 64% 30% 1% 1 5% 2 3 4 Poor Average Good Excellent 10 Vote Now Complex Atrial Fibrillation
Dr Selwyn Wong What was your impression of the presenter’s experMse? 86% 13% 1% 0% 1 2 3 4 Poor Average Good Excellent 10 Vote Now Complex Atrial Fibrillation
Dr Selwyn Wong How well did the speaker d eliver the material and hold the audience? 62% 27% 4% 6% 1 2 3 4 Poor Average Good Excellent 10 Vote Now Syncope
Dr Douglas Scott
How relevant and useful did you find the session? 59% 31% 8% 1% 1 2 3 4 Poor Average Good Excellent 10 Vote Now Syncope
Dr Douglas Scott
Was the material presented in a balanced way? 59% 35% 1% 1 4% 2 3 4 Poor Average Good Excellent 10 Vote Now Syncope
Dr Douglas Scott
What was your impression of the presenter’s experMse? 77% 20% 0% 3% 1 2 3 4 Poor Average Good Excellent 10 Vote Now Syncope
Dr Douglas Scott
How well did the speaker deliver the material and hold the audience? 53% 36% 4% 1 7% 2 3 4 Poor Average Good Excellent 10 Vote Now Overall when considering Session 3:
Did you feel this session was a good investment of your Mme? 1. Yes 95% 2. No 5% 10 Vote Now Overall when considering Session 3:
Was there an appropriate balance of knowledge and interacMve learning? 1. Yes 96% 2. No 4% 10