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Atrial Fibrillation
The document discusses recent advances in the management of atrial fibrillation (AF), including the use of anticoagulants like warfarin and dabigatran for stroke prevention, as well as catheter ablation therapies for maintaining sinus rhythm in symptomatic patients. It highlights studies demonstrating the effectiveness of these treatments and underscores the importance of experienced centers in performing catheter ablation to achieve optimal outcomes. The document emphasizes the significant public health implications of AF and the need for ongoing improvements in treatment strategies.
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Atrial Fibrillation
- 1. ATRIAL FIB BRILLATION New Advances in Management Roy Sauberma MD FACC y an,
- 5. Murgatroyd F, etal.: Lancet 1993;341:1317-22
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- 16. Atrial Fibrillati canseverely ion affect the live of patients, ff t th li es f ti t producing variou symptoms that us reduce the patien Quality of Life nt’s
- 17. Zimetbaum, et al.:PACE 1999;22(Part II):782 C
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- 23. Wolf PA, etal.: Stroke 1991;22:983-8
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- 28. Warfarin (CCoumadin) INR testingrequired (target = 2 3) 2-3) Daily d dosing Generic a available Dabigatran (Pradaxa) n No INR testi required ing Twice daily dosing (75 mg, 150 mg) g No generic available c
- 31. 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 0.66 systemic t i 1.5 15% 1.1 11% 1.7 1 7% 0.34 0 34 <0.001 <0 001 Embolism 0.74-1.11 0.53-0.82 0.92 0 92 0.64 0 64 Stroke 1.4 % 1.0 % 1.6 % 0.41 <0.001 0.74-1.13 0.51-0.81
- 32. 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 <0.00 Total 14.6% 16.4% 18.2% % 0.86- 0.002 0.74-0.83 1 0.97 0.80 0.93 Major 2.7 % 3.1 % 3.4 % 0.003 0.31 0.69-0.93 0.81-1.07 Life- 0.81 0.68 <0.00 Threatening g 1.2 % 1.5 % 5 1.8 % 0.66 0.66- 0.04 4 0.55-0.83 8 1 major 0.99 Gastro- 1.10 1.50 intestinal 1.1 % 1.5 % 1.0 % 0.43 <0.001 0.86 1.41 0.86-1.41 1.19 1.89 1.19-1.89 Major M j
- 33. FDA NEWS RELEASE ForImmediate Release: Oct. 19, 2010 FDA approves Pradaxa to prevent str roke in people with atrial fibrillation The U.S. Food and Drug Administration today approved Pra adaxa capsules (dabigatran etexilate) for the prevention of stroke and blood clots in patients with abnormal heart rhyt thm (atrial fibrillation).
- 34. LAA OCCLUDERS A Investigational
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- 39. J Am CollCardiol 2004:43;1201-8 o
- 40. J Am CollCardiol 2004:43;1201-8 o
- 41. AV NODAL ABLATION •Rapid, uncontrolled ven p , ntricular rates during AF g • Refractory or intolerant o antiarrhythmic therapy y of y y
- 46. AV Nodal Ablation al a
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- 48. Subjective Benefits ofAV Nodal Ablation 1.0 10 110 100 .90 90 .80 80 .70 70 PGWB MHIQ 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
- 49. Objective Benefits ofAV Nodal Ablation f 70 55 mean 54 + 7 50 60 mean 45 40 + 5 mm) mean %) LVESD (m 50 mean LVEF (% 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
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- 53. p<0.01 J Am CollCardiol 2003 Jul 2;42(1):30-2 l
- 54. 5-8% of AFpa 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
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- 56. 2011 ACCF/AHA/HRS FocusedUpdate on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline) n A Report of the Americ College of Cardiology can Foundation/American H Heart Association Task Force on Practice Guidelines Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll
- 57. Ablation Therapy fPatients 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 ned technical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain a database detailing procedures; success and complications engage strategies for continu complications, uous quality improvement, and participate in registries and other efforts pooling data in improvement order to develop optimal care algorithms . Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll
- 58. Ablation Therapy fPatients 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 ned technical guidelines including operator training and experience necessary to maximize ra ates of successful catheter ablation are not available; each center should maintain a database detailing procedures; success and complications engage strategies for continu complications, uous quality improvement, and participate in registries and other efforts pooling data in improvement order to develop optimal care algorithms . Wann LS et al.: J Am C Cardiol 2011;57:223-42 Coll
- 59. AF Tr riggers Haissaguerre, et al.: J Cardiova Electrophysiol 1996;7:1132-44 asc
- 60. AF Tr riggers Haissaguerre, et. al.: N E Engl J Med 1998;339:659-66
- 63. Nathan, et. al.:Circulation 1966;34;412-22 u
- 64. AF Tr riggers Haissaguerre, et. al.: N E Engl J Med 1998;339:659-66
- 66. Li ewire™ TC Live i Ablatio Catheters on Diagnostic Catheters Guiding Introducers Specialty Spiral Catheters Introducers Steerab Diagnostic ble Catheters C
- 70. Wide Area Circum mferential Ablation Oral et al.: Circulat tion 2003;108;2355-60
- 71. Procedural Success P d al S Elimination of Pulmo onary Vein Potentials During A Ablation
- 74. Cryoballoo Ablation C bll on Abl ti
- 76. Cryoballoo Ablation C bll on Abl ti
- 81. STOP AF TRIAL F Sustained Treatment of Paroxysmal Atrial Fibrillati Trial ion
- 83. 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
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- 89. AF ABL LATION Benefits f Risks Bleeding Restoration of sinus rhythm Stroke Pneumothorax Relief of AF-related symptoms AF related Pulmonary vein stenosis P l i t i Elimination of antiarrhythmic Rx Diaphragmatic paralysis ulation Less need for long-term anticoagu Myocardial infarction Esophageal fistula Other atrial arrhythmias
- 90. AF remains am major public h l h issue l health Increasin population at risk ng Significan morbidity & costs g nt y Anticoagulants reduce stroke risk s Warfarin Dabigatra an Drug therapy available for symptom relief a Rate cont agents trol Antiarrhy ythmic drugs y g Catheter-based ablative therapies have emerged d AV nodal ablation to control AF rate l Pulmonary vein isolation to prevent AF recurrence
- 91. Berkeley Heights y Mill lburn Bay yonne