newer guideline

1. MANAGEMENT OF AF WITH
SPECIAL REFERENCE TO ESC 2016
DR AURIOM KAR

2. CLASSIFICATION OF AF ACCORDING TO PATHOGENESIS
• The attempts of the guidelines to link distinct etiological factors with
specific pathophysiological mechanisms are somewhat speculative but
nonetheless interesting because this approach might suggest future line
of research to better understand the pathophysiology of AF.
• The hypothesis that there are different types of AF with distinct pathophysiological
bases is somewhat daring.
• Although the etiological factors can differ, the pathophysiological consequences
are probably similar, and there is no evidence for the hypothesized “distinct
pathophysiological mechanisms” and “different types of AF”, except in very
specific disease and clinical situations.

6. NOAH – AFNET 6
• NOAH – AFNET 6 is a prospective, parallel-group, randomized,
open, double-blind, multi-center trial to evaluate the
potential benefit of oral anticoagulation therapy in patients
with AHRE, but without overt AF. The trial will test whether
treatment with edoxaban, a newly introduced non-vitamin K
antagonist oral anticoagulant (NOAC), is superior to current
therapy to prevent stroke, systemic embolism, or
cardiovascular death in this patient group.
• There is evidence that the stroke rate is increased in patients
with AHRE. A sizeable portion of these patients develop AF
over time. In these patients, AHRE can be considered as an
early manifestation of AF. There is uncertainty about the
optimal antithrombotic therapy in patients with AHRE.
Therefore, we conduct the NOAH – AFNET 6 trial.”

8. COMMENTS
• The new guidelines classify AF episodes that are
cardioverted within 7 days as paroxysmal;
• in previous guidelines, all episodes requiring
cardioversion were considered persistent, even
those lasting less than 7 days. This criteria change
might be confusing and it remains to be seen
whether these definitions will also be adopted by the
guidelines of other scientific societies.
• . A new type of AF is introduced—long-standing
paroxysmal—but is insufficiently explained.

13. COMMENTS
• A CONTROVERSIAL ASPECT IS THE USE OF BIOMARKERS (HIGH-SENSITIVITY
TROPONIN AND N-TERMINAL PRO–B-TYPE NATRIURETIC PEPTIDE) TO STRATIFY
THROMBOEMBOLIC RISK, ALTHOUGH THE RECOMMENDATION IS IIB B.
• THE DIAGNOSTIC AND PROGNOSTIC USEFULNESS OF THESE BIOMARKERS HAS
BEEN SHOWN IN OTHER CARDIOVASCULAR DISEASES BUT CONFIRMATION IS
REQUIRED OF THEIR ADDITIONAL PROGNOSTIC VALUE IN CLINICAL RISK SCALES.
• THE STUDIES CONTRIBUTING TO THE INCLUSION OF THESE BIOMARKERS IN THE
GUIDELINES WERE PERFORMED IN PATIENTS ENROLLED IN LARGE TRIALS
COMPARING VITAMIN K ANTAGONISTS (VKAS) WITH NEW ORAL
ANTICOAGULANTS (NOACS).
• ACCORDINGLY, THE ROLE OF BIOMARKERS IS CONTROVERSIAL BECAUSE ALL
PATIENTS WERE ANTICOAGULATED.
• THEIR USE IN LOW-RISK PATIENTS HAS NOT BEEN VALIDATED AND THEIR ROLE
IN PATIENTS WITHOUT ANTICOAGULATION REMAINS TO BE STUDIED

18. COMMENTS
A list of modifiable risk factors for bleeding is
proposed but no bleeding risk scale is
explicitly recommended.
 Another surprising change is the inclusion of
biomarkers that are not used in daily clinical
practice, such as GDF-15

19. ORBIT-AF
• AGE OLDER THAN 74,
• REDUCED HEMOGLOBIN OR PRESENCE OF ANEMIA OR ABNORMAL
HEMOGLOBIN (HB)/HEMATOCRIT (HCT) (HB <13 G/DL OR HCT <40% FOR
MALES AND HB <12 G/DL OR HCT <36% FOR FEMALES),
• BLEEDING HISTORY,
• INSUFFICIENT KIDNEY FUNCTION (ESTIMATED GLOMERULAR FILTRATION
RATE <60 ML/MIN/1.73 M2
) OR
• TREATMENT WITH ANY ANTIPLATELET DRUG.
 AN ORBIT SCORE OF 0–2 IS CLASSIFIED AS “LOW RISK”,
 WHILE “MODERATE/INTERMEDIATE RISK” IS A SCORE OF 3
AND A
 SCORE ≥4 IS “HIGH RISK”.

20. ATRIA SCORE
Risk factor
Points without prior
stroke
Points with prior
stroke
Age ≥85 6 9
Age 75–84 5 7
Age 65–74 3 7
Age <65 0 8
Female 1 1
Diabetes mellitus 1 1
Chronic heart failure 1 1
Hypertension 1 1
Proteinuriaa
1 1
eGFR < 45 or ESRD 1 1

23. COMMENTS
• A clear preference is expressed for NOACs over VKAs for
nonvalvular AF (I A recommendation).
• However, it seems illogical to reduce the recommendation for
a change to a NOAC when inadequate control of the
international normalized ratio (INR) is achieved with VKAs:
this recommendation was I B in 2012 and is now IIb A.
• A conclusive recommendation is made to avoid the use of
aspirin to prevent stroke, independently of patients’ embolic
risk (III A).
• Theuse of antithrombotics is also discouraged if there is no
specific indication for antiplatelet therapy.

25. COMMENTS
• The guidelines note the importance of
adequate VKA therapy in anticoagulation
control, estimated by the time in therapeutic
range (TTR).
• These antagonists continue to have a I A
recommendation when the TTR is adequate.
• Notably, no cutoff point has been established
for the TTR in this section or in the
recommendation box

26. COMMENTS
• Two interesting differences with previous
guidelines are the clear
declaration of the safety of anticoagulation
with NOACs in patients with mild-to-moderate
chronic kidney disease and the
recommendation to monitor renal function to
enable anticoagulant dose modification and
risk redefinition.

28. Non pharmacological
Left atrial appendage closure
CATHETHER ABLATION

29. REASON FOR CLOT FORMATION IN LAA
• INTENSE FIBROSIS AND INFLAMMATION
SEEEN IN LAA.
• PRESENCE OF PECTINATE MUSCLE-MORE
STASIS

30. PATIENTS IN WHOM LAA CLOSURE IS
CONSIDERED
• Thrombocytopenia or known coagulation defect associated
with bleeding
• Recurrent gastrointestinal bleeding
• Prior severe bleeding, including intracranial hemorrhage
• Combined use of dual antiplatelet and anticoagulant therapy
• Poor compliance with anticoagulant therapy
• High risk of the patient falling or prior falls resulting in injury

31. TRIALS TO EVALUATE WATCHMAN
DEVICE
• PROTECT AF TRIAL
• PREVAIL TRIAL
• ASAP STUDY

32. WATCHMAN DEVICE

33. AMPLATZER CARDIAC PLUG

34. WAVE CREST DEVICE

35. POST IMPLANTATION
NO ABSOLUTE C/I FOR OAC
• WARFARIN PLUS ASP FOR
45 DAYS
• ASPIRIN AND CLOPIDOGREL
FOR FOR 6 MONTH
• ASPIRIN INDEFINATELY
ABSOLUTE C/I OAC
• CLOP AND ASP FOR 6
MONTH
• ASP INDEFINATELY

37. STROKE IN ATRIAL FIBRILLATION
• Ischemic stroke may be the presenting manifestation of atrial fibrillation
(AF) in some patients, while in others it may occur despite appropriate
anticoagulant prophylaxis.
• AF is associated with more severe ischemic strokes and "longer" transient
ischemic attacks than emboli from carotid disease, presumably due to
embolization of larger particles in AF.
• AF is associated with particularly severe ischemic strokes, mostly caused
by relatively large emboli from the left atrial appendage.
• Patients who have had a prior embolic event already have the most
potent high-risk factor for subsequent stroke. The risk of recurrent
stroke in the first few weeks after the initial event is 3 to 5 percent
based upon large numbers of patients observed in the control arms of
randomized trials

38. STROKE IN ATRIAL FIBRILLATION
• FIBRINOLYTIC THERAPHY WHETHER TO GIVE?
• ACUTE ANTITHROMBOTIC THERAPHY .WHEN
TO START?
• OAC-WARFARIN OR NOACS?
• WHAT TO DO IN CASE OF ICH?

39. ISCHEMIC STROKE IN PATIENT TAKING
WARFARIN
INR IN SUBTHERAPEUTIC LEVEL
• TEMPRARY INTERRUPTION
• RENEWED EFFORT TO KEEP
INR IN THERAPEUTIC LEVEL.
INR IN THERAPEUTIC LEVEL
• MOST OFTEN LACUNAR
RELATED TO SMALL VESSEL
ARTERY DISEASE RATHER
THAN OF CARDIOEMBOLIC .
• INCREASE WARF TO INR 2.5
TO 3.5 RATHER THAN
ADDING ANTIPLATELET

40. HEMMORHAGIC STROKE IN PATIENT
TAKING WARFARIN DUE TO AF
• For all patients who develop an ICH, all
anticoagulant and antiplatelet drugs should be
discontinued acutely, and anticoagulant
effects should be reversed immediately.
• Reversal of warfarin-induced anticoagulation.
• Resumption of anticoagulation.

43. COMMENTS
• WARF CAN BE STARTED AFTER 24 HR
• RECOMMENDED TO START NOAC AFTER 48
HRS AS THEY HAVE EARLY ONSET OF
ANTICOAGULENT ACTION

44. RECCOMENDATIONS ON BRIDGING
• Most cardiovascular interventions (e.g. percutaneous
coronary intervention or pacemaker implantation)
can be performed safely on continued OAC.
• When interruption of OAC is required, bridging does
not seem to be beneficial, except in patients with
mechanical heart valves.
• OAC interruptions should be minimized to prevent
stroke.

45. RESUMPTION OF ANTICOAGULATION AFTER
HEMMORRAGIC STROKE
• CLINICAL DILEMA WITH COMPETING RISK AND
BENEFITS

48. CONCERN IF PATIENTS RECEIVING
DOACS BLEED

51. COMMENTS
• A surprising recommendation is to use fresh
frozen plasma inpatients with a bleeding
event and anticoagulated with VKAs. Most
guidelines recommend the use of
prothrombin complex concentrate, given the
lack of efficacy of fresh frozen plasma and its
difficult administration (requiring thawing and
a large volume) and associated secondary
effects

52. REVERSE AD STUDY
IDARUCIZUMAB IN REVERSING
DABIGATRAN TOXICITY

53. ALGORHYTHM TO TREAT BLEEDING DUE
TO DABIGATRAN

54. FACTOR X a ANTIDODE
ANDEXANET ALFA
ANNEXA 4 TRIAL IS ONGOING

55. UNIVERSAL DOAC ANTIDODE
CIRAPARANTAG

60. Comments
 The guidelines have removed the recommendation not to use digitalis
drugs as the only agents for heart rate control in patients with paroxysmal
AF.
 This advice contrasts with North American guidelines, which only consider
BBs and CAs for long-term heart rate control and restrict the use of
digitalis to patients with heart failure
 The guidelines barely consider combined heart rate and rhythm control,
 Atrioventricular node ablation and pacemaker implantation is one way to
achieve heart rate control after drug therapy failure. However, the
guidelines have largely ignored the type of cardiac resynchronization
device, whether single-chamber, dual-chamber, or triple-chamber

63. WHY TO RESTORE SINUS RHYTHM
• TO REDUCE SYMPTOMS
• TO DECERASE STROKE RISK
• TO REDUCE MORTALITY

66. VERNAKALANT THE -NEW ENTRY
 IN BROAD POPULATION OF PATIENTS WITH RECENT ONSET AF
,INCLUDING ELDERLY AND THOSE WITH STRUCTURAL HEART
DISEASE WITHOUT HF VERNALKALANT IS AN EFFECTIVE AND
SAFE FIRST CHOICE IN RAPID CONVERSION OF AF TO SR.
 AS COMPARED TO AMIODARONE IT IS ASSPOCIATED WITH
1. HIGHER CONVERSION RATE
2. SMALLER INCREASE IN QTc
3. HIGHER RATE OF SYMPTOM RELIEF
4. MORE SIGNIFICANT IMPROVEMENT OF QOF

69. ANTICOAGULATION BEFORE AND AFTER
CARDIOVERSION

70. LONG TERM MAINTAINENCE OF
SINUS RHYTHM
• WHOM TO CONSIDER FOR LONG TERM
RHYTHM CONTROL THERAPHY?
• CHOICE OF DRUG?
• NEW ADDITION OF DRONEDARNE IN ESC

73. LONG TERM RHYTHM CONTROL
THERAPHY IN AF

75. COMMENTS ON RHYTHM CONTROL
• THE FIRST MAJOR COMMENT OF THE GUIDELINES IN THIS AREA IS THAT
THE BENEFITS OF RHYTHM CONTROL THERAPY ARE LIMITED TO
SYMPTOM IMPROVEMENT.
• BECAUSE THERE ARE NO DATA ON REDUCED MORTALITY, THERE ARE NO
GUIDELINES FOR ASYMPTOMATIC PATIENTS.
• ABLATION, WHICH IS AWARDED A IIA RECOMMENDATION. THIS CLASS
OF RECOMMENDATION MIGHT BE A SOURCE OF CONTROVERSY DUE TO
THE CONSIDERABLE NUMBER OF RANDOMIZED STUDIES SHOWING THAT
ABLATION IS SUPERIOR TO ANTIARRHYTHMICS IN PATIENTS WITHOUT
PREVIOUS ANTIARRHYTHMIC THERAPY
• STOP-AF , CABANA. MANTRA PAF AND RAFFT 2: TRIALS
SHOW EFFECTIVENESS OF ABLATION OVER DRUGS IN AF

76. COMMENTS ON RHYTHM
CONTROL CONT..
• The guidelines fail to cite any study showing that ablation
boosts ventricular function recovery in patients with either
adequate or inadequate ventricular heart rate control.
• No convincing evidence is put forward showing that ablation
is superior to strict control of ventricular heart rate with node
ablation and subsequent resynchronization device
implantation.
• However, the guidelines do state that ablation is superior to
amiodarone in patients with ventricular dysfunction and an
implantable device.

77. COMBINATION OF RANOLAZINE AND
DRONADERONE
NO PLACE IN GUIDELINE
• HARMONY TRIAL
 Neither placebo nor either drug alone significantly
reduced AFB.
 Conversely, ranolazine 750 mg BID/dronedarone 225
mg BID reduced AFB by 59% vs placebo (p=0.008)
 while ranolazine 750 mg BID/dronedarone 150 mg
BID reduced AFB by 43% (p=0.072). Both
combinations were well tolerated.

80. Types of hybrid therapies
• Antiarrythmic drugs with catheter ablation.
• Antiarrythmic drugs with pacemaker
• Cathether ablation with surgical af procedure

81. COMMENTS ON HYBRID
THERAPHY(2Ac)
• THE GUIDELINES MENTION THE POSSIBLE USE OF CAVOTRICUSPID
ISTHMUS ABLATION AND CONTINUED ANTIARRHYTHMIC DRUG
THERAPY—MAINLY WITH TYPE IC ANTIARRHYTHMIC DRUGS—IN
PATIENTS WITH AF AND ORGANIZED ATRIAL FLUTTER, BUT NO STRENGTH
OF RECOMMENDATION IS PROVIDED.
• IN THE EUROPEAN AND NORTH AMERICAN GUIDELINES FOR
SUPRAVENTRICULAR TACHYCARDIA TREATMENT, A STRONG
RECOMMENDATION (I AND IIA) IS AWARDED TO THIS APPROACH
• A PACEMAKER AND ANTIARRHYTHMIC DRUGS, LARGELY DUE TO THE
NEGATIVE CHRONOTROPIC EFFECTS OF THESE DRUGS. PACEMAKERS
PERMIT THE USE OF HIGHER DOSES OF THESE DRUGS.
• CATHETER ABLATION CAN SOMETIMES OBVIATE THE NEED FOR
ANTIARRHYTHMIC DRUGS AND PACEMAKERS. SOME OF THESE PATIENTS
HAVE REVERSE REMODELING OF THE SINUS NODE, WHICH CAN RETURN
TO NORMAL AFTER AF TERMINATION WITH ABLATION.
• HOWEVER, EARLY SINUS NODE DYSFUNCTION CAN BE UNMASKED

82. CATHETHER ABLATION WITH SURGICAL AF
PROCEDURE
ADVANTAGE
• INITIAL CATHETER ABLATION IS PREFERED FOR
PAROXYSMAL AF
• AF SURGERY IS BETTER AS FIRST OPTION FOR
PERSISTANT LONG ATANDING AF
• REQUIREMENT OF LESS RF ENERGY –SO LESS
COLLORARY DAMAGE TO SURROUNDING
STRUCTURE VIZ .ESOPHAGUS
• ENDOCARDIAL “TOUCH-UP” BY CATHETER
AFTER SURG
• REDUCED TIME IN LA SO LESS EMBOLISM AND
STROKE ,,LESS FLURO TIME.
• INTRAOPERATIVE VALIDATION OF THE
SURGICAL ABLATION MOST RELIABLE END
POINT FOR AN EFFECTIVE PVI IS THE
CONFIRMATION OF BIDIRECTIONAL
CONDUCTION BLOCK THROUGH THE BOX
LESION(INTRAOP REQ OF EP STUDY). TAILORED
DELIVERY OF RF APPLICATIONS, UNTIL SUCH
END-POINTS ARE MET, THEREBY REPRODUCING
THE EP CRITERIA FOR SUCCESS ALSO IN THE
SURGICAL SETTING.
DISADVANTAGE
• FALSE POSITIVES CONSIST IN EARLY
INDUCIBLE POSTOPERATIVE ATRIAL
ARRHYTHMIAS DETECTED BY EP MAY
BE DUE TO ATRIAL ODEMA DUE TO
SURG.
• ACUTE DEMONSTRATION OF A
BIDIRECTIONAL BLOCK COULD ONLY
BE TRANSIENT AND NOT CONFIRMED
BY DELAYED TESTING AT ONE
MONTH AFTER SURGERY.
• HEPARINIZATION FOLLOWING THE
TRANS-SEPTAL PUNCTURE WHICH
COULD INCREASE THE RISK OF
EPICARDIAL BLEEDING
• AVAILABILITY OF TWO SEPARATE TEAMS
(SURGEONS AND
ELECTROPHYSIOLOGISTS) DURING AN
OVERALL TIME-CONSUMING PROCEDURE

83. Hybrid Staged Operating Room and
Interventional Catheter Ablation
for Atrial Fibrillation (HISTORIC-AF)
CREATION OF CARDIAC LESION WITH
EPICARDIALY APPLIED RF ABLATION THROUGH
MIS APPROACH FOLLOWED BY DELAYED EP
ABLATION 1-2 MONTH AFTER SURGICAL
OPERATION

84. THANK U