Atrial Fibrillation

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Atrial fibrillation (AF) is the most frequently diagnosed cardiac rhythm disorder. It affecting 2.5 million people in the United States, and may be associated with an increased risk for death, congestive heart failure, and stroke. Our cardiac electrophysiologist will review the latest treatment options for patients with AF, including recent advances in pharmacologic therapy to keep patients heart rhythms normal. He also will discuss catheter ablation to eliminate sources of AF and anticoagulation to prevent thromboembolic strokes. Presented by Summit Medical Group cardiologist, Roy Sauberman, MD, FACC

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Atrial Fibrillation

  1. 1. ATRIAL FIB BRILLATIONNew Advances in Management Roy Sauberma MD FACC y an,
  2. 2. Murgatroyd F, et al.: Lancet 1993;341:1317-22
  3. 3. www.escardio.org/guidelines
  4. 4. www.escardio.org/guidelines
  5. 5. Atrial Fibrillati can severely ion affect the live of patients, ff t th li es f ti t producing variou symptoms that usreduce the patien Quality of Life nt’s
  6. 6. Zimetbaum, et al.: PACE 1999;22(Part II):782 C
  7. 7. Jung, et al.: J Am Coll Cardiol 1999;33(2):104A
  8. 8. www.escardio.org/guidelines
  9. 9. Wolf PA, et al.: Stroke 1991;22:983-8
  10. 10. www.escardio.org/guidelines
  11. 11. www.escardio.org/guidelines
  12. 12. www.escardio.org/guidelines
  13. 13. www.escardio.org/guidelines
  14. 14. Warfarin (CCoumadin)INR testing required (target = 2 3) 2-3) Daily d dosing Generic a available Dabigatran (Pradaxa) n No INR testi required ingTwice daily dosing (75 mg, 150 mg) g No generic available c
  15. 15. Stro oke D 110mg vs. D 150mg vs. D 110mg D 150mg warfar rin Warfarin Warfarin Annual Annual Annuaal RR RR P P rate t rate t rate t 95% CI % 95% CI %Stroke or 0.91 0.66systemic t i 1.5 15% 1.1 11% 1.7 1 7% 0.34 0 34 <0.001 <0 001Embolism 0.74-1.11 0.53-0.82 0.92 0 92 0.64 0 64Stroke 1.4 % 1.0 % 1.6 % 0.41 <0.001 0.74-1.13 0.51-0.81
  16. 16. Bleeding g D D D 110mg vs. D 150mg vs. Warfar rin 110mg 150mg Warfarin Warfarin Annual Annual Annuaal RR RR p p rate rate rate 95% CI 95% CI 0.91 0 91 0.78 <0.00Total 14.6% 16.4% 18.2% % 0.86- 0.002 0.74-0.83 1 0.97 0.80 0.93Major 2.7 % 3.1 % 3.4 % 0.003 0.31 0.69-0.93 0.81-1.07Life- 0.81 0.68 <0.00Threatening g 1.2 % 1.5 % 5 1.8 % 0.66 0.66- 0.04 4 0.55-0.83 8 1major 0.99Gastro- 1.10 1.50intestinal 1.1 % 1.5 % 1.0 % 0.43 <0.001 0.86 1.41 0.86-1.41 1.19 1.89 1.19-1.89MajorM j
  17. 17. FDA NEWS RELEASEFor Immediate Release: Oct. 19, 2010FDA approves Pradaxa to prevent str roke in people with atrial fibrillationThe U.S. Food and Drug Administration today approved Pra adaxa capsules (dabigatran etexilate) for the prevention ofstroke and blood clots in patients with abnormal heart rhyt thm (atrial fibrillation).
  18. 18. LAA OCCLUDERS A Investigational
  19. 19. www.escardio.org/guidelines
  20. 20. www.escardio.org/guidelines
  21. 21. J Am Coll Cardiol 2004:43;1201-8 o
  22. 22. J Am Coll Cardiol 2004:43;1201-8 o
  23. 23. AV NODAL ABLATION• Rapid, uncontrolled ven p , ntricular rates during AF g• Refractory or intolerant o antiarrhythmic therapy y of y y
  24. 24. AV Nodal Ablation al a
  25. 25. Pacemaker Required r
  26. 26. Subjective Benefits of AV Nodal Ablation 1.0 10 110 100 .90 90 .80 80 .70 70 PGWBMHIQ 70 .60 60 .50 p < 0.01 p < 0.01 50 .40 40 40 0 30 Pre Post Pre Post McMaster Health Index Questionnaire physical Psychological General Well-Being Index scores dimension scores before and after procedure. before and after procedure. High score = High score = better functional capacity. greater perception of health and well-being. Kay GN, et al.: Am J Cardiol 1988;62:741-4
  27. 27. Objective Benefits of AV Nodal Ablation f 70 55 mean 54 + 7 50 60 mean 45 40 + 5 mm) mean %) LVESD (m 50 meanLVEF (% 43 + 8 40 34 + 5 35 40 p < 0 001 0.001 30 p < 0 003 0.003 30 25 20 20 Before After Before After LVEF (%) LVESD (mm) Rodriguez LM, et al.: Am J Cardiol 1993;72:1137-41 m
  28. 28. Amio
  29. 29. p<0.01J Am Coll Cardiol 2003 Jul 2;42(1):30-2 l
  30. 30. 5-8% of AF pa atients remain highly symp g y ymptomatic, ,require at least one ca ardioversion per year, despite antiarrhythm drug therapy !! mic Seidl K, et al.: J Am Coll Cardiol 1999;33(2):146A
  31. 31. www.escardio.org/guidelines
  32. 32. 2011 ACCF/AHA/HRS Focused Update on the Management ofPatients With Atrial Fibrillation (Updating the 2006 Guideline) nA Report of the Americ College of Cardiology canFoundation/American H Heart Association TaskForce on Practice Guidelines Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll
  33. 33. Ablation Therapy f Patients with bl i h y for i ih Paroxysmal Attrial Fibrillation Class I Catheter ablation performed in e experienced centers* is useful in maintaining sinus rhythm i sele t d patients with significantly i t i i i h th in lected ti t ith i ifi tl symptomatic, paroxysmal AF wh have failed treatment with an ho antiarrhythmic drug and have no y g ormal or mildly dilated left atria, y normal or mildly reduced LV funnction, and no severe pulmonary disease. (Level of Evidence: A)*Refers to pulmonary vein isolation with catheter ablation. An experienced center is defin as one performing more than 50 AF catheter ablation cases per year. Evidence-based nedtechnical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain adatabase detailing procedures; success and complications engage strategies for continu complications, uous quality improvement, and participate in registries and other efforts pooling data in improvementorder to develop optimal care algorithms . Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll
  34. 34. Ablation Therapy f Patients with bl i h y for i ih Paroxysmal Attrial Fibrillation Class I Catheter ablation performed in e experienced centers* is useful in maintaining sinus rhythm i sele t d patients with significantly i t i i i h th in lected ti t ith i ifi tl symptomatic, paroxysmal AF wh have failed treatment with an ho antiarrhythmic drug and have no y g ormal or mildly dilated left atria, y normal or mildly reduced LV funnction, and no severe pulmonary disease. (Level of Evidence: A)*Refers to pulmonary vein isolation with catheter ablation. An experienced center is defin as one performing more than 50 AF catheter ablation cases per year. Evidence-based nedtechnical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain adatabase detailing procedures; success and complications engage strategies for continu complications, uous quality improvement, and participate in registries and other efforts pooling data in improvementorder to develop optimal care algorithms . Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll
  35. 35. AF Tr riggersHaissaguerre, et al.: J Cardiova Electrophysiol 1996;7:1132-44 asc
  36. 36. AF Tr riggersHaissaguerre, et. al.: N E Engl J Med 1998;339:659-66
  37. 37. Nathan, et. al.: Circulation 1966;34;412-22 u
  38. 38. AF Tr riggersHaissaguerre, et. al.: N E Engl J Med 1998;339:659-66
  39. 39. Li ewire™ TC Live i Ablatio Catheters onDiagnostic Catheters Guiding Introducers Specialty Spiral Catheters Introducers Steerab Diagnostic ble Catheters C
  40. 40. Wide Area Circum mferential Ablation Oral et al.: Circulat tion 2003;108;2355-60
  41. 41. Procedural Success P d al SElimination of Pulmo onary Vein Potentials During A Ablation
  42. 42. Cryoballoo AblationC b ll on Abl ti
  43. 43. Cryoballoo AblationC b ll on Abl ti
  44. 44. STOP AF TRIAL FSustained Treatment of Paroxysmal Atrial Fibrillati Trial ion
  45. 45. STOP AF TRIAL F• Palpitations decreased from 86% to 25% d• Fatigue decreased from 76% to 13% m• Rapid heartbeat decre eased from 66% to 16%• Diffi lt b thi decreased from 54% to 9% Difficulty breathing df t• Dizziness decreased fr rom 48% to 9%• Fainting decreased fro 4% to 1% om• Overall quality of life significantly improved
  46. 46. Hansen Robotic System b y
  47. 47. Hansen Robotic System b y
  48. 48. AF ABL LATION Benefits f Risks BleedingRestoration of sinus rhythm Stroke PneumothoraxRelief of AF-related symptoms AF related Pulmonary vein stenosis P l i t iElimination of antiarrhythmic Rx Diaphragmatic paralysis ulationLess need for long-term anticoagu Myocardial infarction Esophageal fistula Other atrial arrhythmias
  49. 49. AF remains a m major public h l h issue l health Increasin population at risk ng Significan morbidity & costs g nt yAnticoagulants reduce stroke risk s Warfarin Dabigatra anDrug therapy available for symptom relief a Rate cont agents trol Antiarrhy ythmic drugs y gCatheter-based ablative therapies have emerged d AV nodal ablation to control AF rate l Pulmonary vein isolation to prevent AF recurrence
  50. 50. Berkeley Heights y Mill lburn Bay yonne

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