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Update on Atrial Fibrillation Management Dr Lim Toon Wei Consultant Cardiologist National University Heart Centre, Singapore (NUHCS) Research 4 August 2012 Clinical Care Education Dr Lim Toon Wei MBBS(Hons) FRACP PhD Consultant Cardiologist Agenda: Dr Lim Toon Wei 1. 2. 3. 4. 5. The problem of AF. Diagnosing AF Complications and adverse outcomes of AF How to investigate a patient with new onset AF Drug therapy: Rate vs. rhythm control Agenda 1. 2. 3. 4. 5. The problem of AF. Diagnosing AF Complications and adverse outcomes of AF How to investigate a patient with new onset AF Drug therapy: Rate vs rhythm control “AF is the most common clinically significant cardiac arrhythmia” arrhythmia” Source: Almost any paper on AF AF: a growing burden of disease US: 3.8-8.9 million in 2025 US: 5.6-15.9 million in 2050 Age standardized prevalence increasing Naccarelli et al. Am J Cardiol 2009;104:1534–1539 Prevalence of AF in Singapore Occurs in ~0.5–1% of general population1 Overall Singapore prevalence of 1.5% (Singapore Longitudinal Aging Study)2 2.6% in males vs. 0.6% in females >55 rs old 5.8% for those > 80yrs Majority (> 90%) of AF are of nonvalvular 1. MOH CPG 8/2004 Management of Afib; 2. Yap KB et al. Journal of Electrocardiology 41 (2008) 94–98 What is AF? 心房颤动 心房颤动 Apparently chaotic electrical activity in atria Atrial remodelling Fibrosis Electrical remodelling Dedifferentiation Associated most commonly with Hypertensive heart disease Coronary artery disease Rheumatic heart disease (less common) Moe’s Multiple wavelet theory Agenda 1. 2. 3. 4. 5. The problem of AF. Diagnosing AF Complications and adverse outcomes of AF How to investigate a patient with new onset AF Drug therapy: Rate vs. rhythm control Diagnosing AF: Classification Paroxysmal AF: <7days Persistent AF: >7days Longstanding Persistent AF: >1 year Permanent AF: Cardioversion not possible or not attempted Lone AF Symptoms Palpitations Dyspnoea Fatigue, weakness Chest pain/discomfort “Giddiness” Stroke Precipitants: Alcohol, exercise, emotion “My doctor says I have an abnormal ECG” Signs Irregularly irregular pulse Heart failure Raised JVP Bibasal crepitations S3, S4 Peripheral oedema MR or MS murmur f waves Irregularly irregular •Anteroseptal Q waves •Late R progression •Lateral T wave inversion •Left axis deviation (left anterior hemiblock) •Widespread ST depressions AF with Complete Heart Block http://www.heartpearls.com/2009/08/ecg-image-014.html Pre-excited AF Turakhia MP et al. Indian Pacing Electrophysiol. J. 2009;9(2):130-133 Pre-excited AF: Post Cardioversion Turakhia MP et al. Indian Pacing Electrophysiol. J. 2009;9(2):130-133 Shortest pre-excited RR interval <250 ms is a risk factor for SUDDEN DEATH. Triedman J K Heart 2009;95:1628-1634 Atrial Flutter •Atrial cycle length approx 200ms (300bpm) •Typically in RA around tricuspid annulus •First line therapy is radiofrequency ablation 心房扑 心房扑动 Agenda 1. 2. 3. 4. 5. The problem of AF. Diagnosing AF Complications and adverse outcomes of AF How to investigate a patient with new onset AF Drug therapy: Rate vs. rhythm control AF doubles mortality Framingham Heart Study 55-74 year olds Benjamin EJ et al. Circulation 1998;98;946-952 AF doubles mortality Framingham Heart Study 75-94 year olds Benjamin EJ et al. Circulation 1998;98;946-952 Stroke in AF Increased risk in patients with AF even without prior stroke Frost et al. Am J Med. 2000;108(1):36 • Further increased in patients with risk factors, regardless of AF subtype Hart et al. J Am Coll Cardiol 2000;35:183–7 Age Strokes per 100 patient years 50 to 59 1.3 60 to 69 2.2 70 to 79 4.2 80 to 89 5.1 Copenhagen Stroke Study: AF Related Strokes are More Severe and Cause More Disability Jørgensen HS et al.Stroke. 1996;27:1765-1769 With AF Without AF Univariate P Initial stroke severity* 29.7±17.0 37.5±17.0 <.0001 Initial disability (Barthel Index) 34.5±39.1 51.7±41.3 <.0001 Length of hospital stay, d 50.4±49.9 39.8±44.6 <.001 In-hospital mortality, n (%) 72 (33) 171 (17) <.00001 Discharged to nursing home, n (%) 41 (19) 135 (14) .06 Discharged to own home, n (%) 104 (48) 662 (69) <.00001 Neurological outcome‡ 46.3±14.3 49.8±12.2 .003 Functional outcome§ 66.8±38.0 78.0±32.8 .0007 Framingham: AF Related Strokes Lead to More Death and Recurrences. More deaths 63% vs. 34% at 1 year More recurrences 23% vs. 8% at 1 year Lin HJ et al. Stroke. 1996;27:1760-1764 Prevalence of Stroke in Singapore Prevalence of 4.05% for over 50y.o. population. Age (years) 50-54 65-69 >85 Prevalence (CI) 0.67 (0.43–1.05) 4.75 (3.93–5.72) 14.86 (11.60–18.83) Fourth most common cause of mortality in Singapore (1,500 per year) 10% of these are cardioembolic strokes Narayanaswamy Venketasubramanian et al. Am Stroke Association 2005 36 (3), P 551 – 556 Agenda 1. 2. 3. 4. 5. The problem of AF. Diagnosing AF Complications and adverse outcomes of AF How to investigate a patient with new onset AF Drug therapy: Rate vs. rhythm control Investigations 1 ECG LVH Q waves Pre-excitation Bundle branch block QT interval Investigations 2: Blood tests Electrolytes, urea, creatinine FBC Thyroid function Fasting glucose Look for underlying cause: Sepsis ○ CXR ○ Urinalysis ○ Blood cultures Investigations 3: Echocardiogram Evaluate for structural heart disease Valvular heart disease LVH Heart failure Ischaemic heart disease Left atrial size Any structural heart disease Holter study Suspected AF Rate control Agenda 1. 2. 3. 4. 5. The problem of AF. Diagnosing AF Complications and adverse outcomes of AF How to investigate a patient with new onset AF Drug therapy: Rate vs. rhythm control AF Management Rate control Drug Ablate and pace Rhythm control Drug Ablation Cardioversion Anticoagulation Rate Control Drugs β-blocker Non-dihydropyridine CCB Verapamil Diltiazem Amiodarone Digoxin Acute rate control Betablockers or CCB Consider amiodarone if in heart failure If haemodynamically unstable, then urgent cardioversion. Should be followed by long term rate control Rate Control: Drug (2) Important points to note: 1. Patients with pre-excitation: a) b) DO NOT USE pure AV blocking agents e.g. β-blocker, CCB, digoxin Instead use procainamide, amiodarone. Rate Control: Drug (3) 2. Use of β-blocker, CCB in acute HF can worsen compromise a. Use digoxin or amiodarone b. Consider electrical cardioversion 3. Avoid digoxin in physically active individuals with PAF. May cause excessive tachycardia during stress Rhythm control: Drugs Class III drugs *Amiodarone *Dronedarone *Sotalol (less effective) Dofetilide Ibutilide Class Ic drugs *Flecainide * Propafenone Can lead to flutter (use with β-blocker) *Available in Singapore Rhythm control: Drugs Modest of no efficacy: Digoxin Quinidine Procainamide β-blocker Acute Rhythm Control: Cardioversion Electrical or pharmacological Needs anticoagulation TOE to look for LA thrombus Similar risk of thromboembolism Electrical cardioversion more effective But requires sedation/ airway management Flecainide and procainamide most effective drugs. Amiodarone less effective Transoesophageal echocardiogram of left atrial appendage thrombus (white arrow) WJ Manning.The American Journal of Cardiology, 1997. 80(4), Supp 3:19D–28D Long Term Rate Control Resting heart rate ≤80 beats/min ≤110 beats/min during moderate exercise Less strict criteria may be equally effective RACE II trial Conventional rate control criteria vs <110bpm at rest Primary outcome: cardiovascular death, hospitalization for heart failure, and stroke, systemic embolism, bleeding, and life-threatening arrhythmic events. 3year estimated incidence with lenient control was non-inferior (12.9 vs. 14.9 %) Reasonable for less symptomatic patients Van Gelder IC et al. N Engl J Med 2010; 362:1363. Choice of drugs: Beta Blockers Beta blockers Most commonly used IV and PO available Carvedilol may have additional benefits in chronic heart failure Choice of drugs: CCB Verapamil and diltiazem Avoid in heart failure May exacerbate sick sinus syndrome Verapamil reduces renal clearance of digoxin Choice of drugs: Digoxin Less effective Especially with exercise Maybe useful in heart failure Choice of drugs: Amiodarone Commonly used, less negative inotropy But many long term side effects, hence not first line for rate control. Long Term Rhythm Control Often in addition to rate control drugs. Choice depends on whether patients have structural heart disease, heart failure Serious side effects with some drugs Proarrhythmia and sudden death Liver toxicity No Structural Heart Disease Class 1C: Flecainide, propafenone Class 3: Sotalol Beta blocker trial reasonable Monitor for prolongation of QRS >150% of baseline Monitor for QTc >520ms Monitor renal function (especially sotalol) Amiodarone?: most effective, most side effects Interacts with warfarin Lung (1-2% at <400mg per day) Thyroid (2-24%) Liver (15-50% have increase AST/ALT) Cirrhosis <3% Eye: Corneal deposits 90% Skin photosensitivity: 25-75% GI intolerance: 30% Torsade de pointes (rare) Dronedarone Amiodarone sans iodine Preferred by some due to fewer side effects Less effective than amiodarone Increased deaths and major events in heart failure patients (ANDROMEDA, PALLAS) Expensive Patients with Structural Heart Disease Includes LVH Avoid flecainide (propafenone): especially if IHD Avoid dronedarone in heart failure Hence, amiodarone is usually first choice What to look out for in patients on antiarrhythmic drugs Bradycardia (all) QTc >500ms (all) QRS >150% baseline (Class 1C) Renal impairment (sotalol, class 1C) Electrolyte disturbance (all) Hepatic impairment (amiodarone, dronedarone) Thyroid dysfunction (amiodarone) Rate vs. Rhythm Control Remains unclear AFFIRM and RACE both found no difference, but trend favouring rate control Older patients Allowed discontinuation of warfarin Patients in SR did better Studies pre-date catheter ablation Canadian Healthcare Database Increased mortality in rhythm control arm at 6 months (HR1.07) Similar at 4 years Rhythm control superior thereafter! But: Old cohort (mean 79 years old) Observational What does it all mean??? Both strategies reasonable Old, few symptoms rate control Young, active rhythm control Symptoms despite rate control rhythm control Dr Lim Toon Wei MBBS FRACP PhD Consultant Cardiac Department NUHCS [email protected] Ph: 67725286 Thank you for your attention Research Clinical Care Education