AFIB SUMMIT 20015

1. Subodh K. Agrawal, MD
• Interventional Cardiologist at
Athens Heart Center
• Board Certified in Internal
Medicine, Cardiovascular
Diseases, Interventional
Cardiology, and Sleep Medicine
• Special interests are coronary
artery disease, sleep disorders
and their connection to cardiac
function, healthcare education,
and finding ways to help reduce
costs while improving the quality
of healthcare in the U.S.
Medical School:
Sawai Man Singh Medical College
Residency:
Emory University
Hospital
Fellowship:
Emory University
Hospital

2. Synergy

3. Atrial Fibrillation
(Defined)
AF is an arrhythmia characterized by
uncoordinated atrial activation, with
consequent deterioration of atrial mechanical
function
Circulation 2011; 121: e269-e367

4. 0
2
4
6
8
10
12
14
16
18
Year
ProjectedNumberofPeoplewithAF
(millions)
Miyakasa Y, et al. Circulation. 2006; 114:119-125.
Atrial Fibrillation: An Epidemic
16 millionUS
Prevalence
1 in 4 lifetime risk in men and women ≥ 40 years old

5. Paroxysmal
Self-Terminating
Persistent
Lasts > 7 Days
Permanent
Cardioversion
Failed or Not
Attempted
Normal Sinus Rhythm
Atrial Fibrillation
The “3 Ps” and Natural History of Atrial Fibrillation
Paroxysmal AF is as likely
to cause stroke as
persistent or permanent AF

6. Controversies in Atrial Fibrillation
• Rhythm vs rate control
• Definition of optimum rate control
• Need for early cardioversion to prevent remodeling
• Electric vs pharmacological cardioversion
• Selection of patient for long term anticoagulation
• Warfarin vs novel anticoagulation agents
• Ablation therapy how much to ablate
• Relationship between mechanism and therapy

7. We Aim To Move Perception To Reality
AF REALITY
AF is a severe CV disease
within the CV continuum
AF has direct morbidity and
mortality impact
AF PERCEPTION
An isolated low risk disease
requiring symptom
management and stroke
prevention
7

8. Atrial Fibrillation VS Current Management

9. Interactive Questions

10. An 82 year old man is in your office for an annual Medicare
physical.
What is the chance he has atrial fibrillation?
A. 1%
B. 5%
C. 10%
D. 25%

11. 0.1 0.4
1.0
1.7
3.4
5.0
7.2
9.1
0.2
0.9
1.7
3.0
5.0
7.3
10.3
11.1
0.0
2.0
4.0
6.0
8.0
10.0
12.0
<55 55-59 60-64 65-69 70-74 75-79 80-84 > 85
Women
Men
Prevalence of Diagnosed AF
Go AS, JAMA. 2001 May 9;285(18):2370-5. Pub Med PMID: 11343485
# Women 530 310 566 896 1498 1572 1291 1132
# Men 1529 634 934 1426 1907 1886 1374 759
Stratified by Age and Sex
x-axis = %
y-axis = # of
men/women

12. A 46 year old male patient is in for an annual physical exam.
What is his lifetime risk of developing AF?
A) 1%
B) 5%
C) 10%
D) 25%

13. 68 year old female with atrial fibrillation, a past history
of Myocardial infarction, and no other co-morbidities.
How would you classify her stroke risk?
What is her CHADS2 score?
A) 0
B) 1
C) 2

14. What is her CHA2DS2-VASc score?
A) 1
B) 2
C) 3

15. AF PIE
FUTURE
AF PIE
PAST
Fuster V. Circulation 2012; epubl April 18

16. 78 year old male with atrial fibrillation and
hypertension (CHADS2 score = 2 [4% stroke rate
per year]).
What is his annual major bleeding rate?
A) 1%
B) 2%
C) 3%
D) 5%
E) 10%

17. • 78 year old female with atrial fibrillation, hypertension
and CHF.
• CHADS2 = 3
• CHA2DS2-VASc = 5
• HAS-BLED = 2
What would you use for stroke prevention?
A) No anti-thrombotics
B) Aspirin
C) Aspirin + clopidogrel
D) VKA antagonist
E) Dabigatran or Rivaroxaban

18. 69 year old lady with palpitation. Holter revealed
transient AF lasting for 3-10 minutes with rate of 140 to
150, otherwise NSR. She has history of stroke in the
past of an unknown origin, from which she has
recovered completely.
What should you do?
A) Start rate control and anticoagulation
B) Start rhythm control and anticoagulation
C) Start ASA

19. A 71-year-old white female with a history of chronic, non-
valvular AF, controlled hypertension, and a history of mild
congestive heart failure has been evaluated by a
cardiologist and found to be a non suitable candidate for
warfarin therapy. Due to logistical barriers that make
monitoring difficult and dietary variations, the patient has
had difficulty controlling her INR.
What should you do?
A) Replace Warfarin with aspirin
B) Replace Warfarin with aspirin + clopidogrel
C) Replace Warfarin with a non-monitored oral
anticoagulant

20. • An 81-year-old white female with a history of chronic, non-valvular
AF, a history of a previous ischemic stroke, and a history of mild
congestive heart failure has been on a combination of clopidogrel
and aspirin therapy because she was found to be intolerant of
warfarin. She is admitted to the hospital for a GI bleed, and is found
to have a hematocrit of 29 and a hemoglobin of 9.8. A bleeding
colon poly resected and no further GI bleeding occurred and patient
HCT normalized. The aspirin and clopidogrel are discontinued. The
patient stabilizes, and the cardiologist is consulted to determine the
subsequent course of her antithrombotic treatment. She has a HAS-
BLED score of 3.
Which of these better describes your opinion?
A) Because of the documented GI bleed, the patient should not be
treated with antithrombotic agents, because the risk of bleeding
outweighs the risk of stroke and its complications.
B) Because of the patient's risk profile, there should be an attempt to
provide thromboprophylaxis against embolic stroke.

21. At this point you would most likely:
A) Try the patient on warfarin again
B) Try to re-introduce clopidogrel and aspirin
C) Treat the patient with aspirin alone
D) Introduce a non-monitored oral
anticoagulant to the patient's regimen.