Download Update on Atrial Fibrillation Management

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