CME Lecture for the medical staff at St Vincent's Hospital.
Atrial fibrillation is a common rhythm disorder. There are many treatment options available today.
Heart Failure with Preserved Ejection Fraction(HFpEF).ptxSarfraz Saleemi
Heart failure with preserved ejection fraction (HFpEF) is not one disease but a clinical syndrome presenting with symptoms of Heart Failure with a left ventricular ejection fraction (LVEF) ≥50 percent and evidence of cardiac diastolic dysfunction. (abnormal LV filling pattern and elevated filling pressures)
It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance. HFpEF should be part of differential diagnosis in patients with typical symptoms such as fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema and clinical signs of chronic heart failure. Echocardiography features of normal ejection fraction with impaired diastolic function confirm the diagnosis.
Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.
Heart Failure with Preserved Ejection Fraction(HFpEF).ptxSarfraz Saleemi
Heart failure with preserved ejection fraction (HFpEF) is not one disease but a clinical syndrome presenting with symptoms of Heart Failure with a left ventricular ejection fraction (LVEF) ≥50 percent and evidence of cardiac diastolic dysfunction. (abnormal LV filling pattern and elevated filling pressures)
It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance. HFpEF should be part of differential diagnosis in patients with typical symptoms such as fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema and clinical signs of chronic heart failure. Echocardiography features of normal ejection fraction with impaired diastolic function confirm the diagnosis.
Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
Atrial fibrillation (afib) is one of the main causes of strokes in the US. New treatment options are available - both medical therapy (such as new blood thinners) and procedures (watchman left atrial appendage closure).
A US Food and Drug Administration advisory panel voted 7 to 5 in favor of approving a device for closure of the left atrial appendage (LAA) as an alternative to long-term warfarin therapy for the prevention of stroke in warfarin-eligible patients with nonvalvular atrial fibrillation (AF).
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
Atrial fibrillation (afib) is one of the main causes of strokes in the US. New treatment options are available - both medical therapy (such as new blood thinners) and procedures (watchman left atrial appendage closure).
A US Food and Drug Administration advisory panel voted 7 to 5 in favor of approving a device for closure of the left atrial appendage (LAA) as an alternative to long-term warfarin therapy for the prevention of stroke in warfarin-eligible patients with nonvalvular atrial fibrillation (AF).
Atrial fibrillation (afib) is a heart rhythm disorder (arrhythmia). It increases your risk of having a stroke and can affect your quality of life. There are many treatment options for patients with atrial fibrillation (afib).
In order to decrease the burden of the symptoms from afib, we can use medications or procedures - catheter ablation.
Patients with afib have a 5 fold higher risk of having a stroke. Traditionally blood thinners are used to decrease that risk. A new option available as an alternative to blood thinners is the Watchman left atrial appendage closure device.
All You Need to Know About Atrial FibrillationSummit Health
Atrial fibrillation is the most common arrhythmia,
particularly as people age. It can cause stroke,
heart failure, and many symptoms. There are
very effective therapies today, including
anticoagulants and catheter ablation.
Warfarin is an anticoagulant normally used in the prevention of thrombosis and thromboembolism, the formation of blood clots in the blood vessels and their migration elsewhere in the body, respectively.
WATCHMAN™ Left Atrial Appendage Closure Device is a first-of-its-kind, proven alternative to long-term warfarin therapy for stroke risk reduction in patients with non-valvular atrial fibrillation.
Ponencia presentada por el Dr. Raúl Moreno Gómez en el directo online ‘Anticoagulación de cine en el paciente mayor’, realizado el 13 de febrero de 2020 en la Casa del Corazón.
Similar to Atrial Fibrillation - From Diagnosis to Treatment - St Vincent's Birmingham (20)
High Frequency Low Tidal Volume Ventilation during AF ablationJose Osorio
High Frequency Low Tidal Volume ventilation during ablation of Afib can significantly improve catheter stability.
After concluding a single center experience, we implemented the technique in a large multi center network, with significant improvements in procedural time while maintaining safety outcomes.
Fluoroscopic reduction in a fib ablation - Ready for Prime Time?Jose Osorio
My journey with fluoroscopy reduction in AF ablation started back in 2010. ICE has been an integral part of the safe elimination of fluoroscopy for most of our procedures.
Over the past several years, we have shown that these techniques are safe, effective and can be performed efficiently. We have taught many electrophysiologists who have been able to replicate these results.
Quality Improvement in an AF Ablation ProgramJose Osorio
Atrial fibrillation ablation is an important treatment options for patients with AF. The number of AF ablations continue to rise annually but there is a limited number of Electrophysiology Laboratories and doctors. With the increasing prevalence of Afib, many institutions are finding bottlenecks with the increase volume.
We propose that a quality improvement initiative is the ideal way to improve efficiency, outcomes and safety of AF ablations with the end results being more patients treated with good results.
Standardizing Care and Increasing Efficiency in an Atrial Fibrillation ProgramJose Osorio
As the number of patients with afib continue to increase in the US, there is a growing need for Afib ablations. With a limited number of EP labs and doctors, each hospital will have to find safe ways to increase their number of procedures to meet the demand.
Our experience shows that by standardizing care and following guidelines and internal protocols, AF ablation programs can increase safety and efficacy while improving efficiency.
The Evolution of Atrial Fibrillation Ablation: Utilizing Current Technology ...Jose Osorio
The treatment of atrial fibrillation is rapidly evolving. Grandview Medical Center in Birmingham Alabama has a comprehensive afib center. We have extensive experience in the treatment and ablation of atrial fibrillation. Our experience was presented at the Asia Pacific Heart Rhythm Society Meeting - APHRS, in Tokyo.
Our workflow has led to significant improvements in success rates while procedure times were reduced. More importantly we have maintained very good safety profile.
Introduction to Electrophysiology - Ventricular Arrhtyhmias and Cardiac Devic...Jose Osorio
What is cardiac Electrophysiology?
This presentation will cover basics of EP. It is Part 2 of 4 lectures about EP.
Part 1 - basics of EP and Supraventricular Tachycardias (SVT)
Part 2 - Ventricular arrhythmias and Cardiac Devices
Part 3 - Afib
Part 4 - EKG
Introduction to Electrophysiology - Supraventricular Tachycardias (1/4 lectures)Jose Osorio
What is cardiac Electrophysiology?
This presentation will cover basics of EP. It is Part 1 of 4 lectures about EP.
Part 1 - basics of EP and Supraventricular Tachycardias (SVT)
Part 2 - Ventricular arrhythmias and Cardiac Devices
Part 3 - Afib
Part 4 - EKG
Atrial fibrillation (or afib) is a common heart rhythm disorder. It can cause many symptoms, such as fatigue or palpitations, and also increase your risk of having a stroke.
There are many treatment options for patients with afib. Patients need to have treatment to reduce their risk of stroke and to decrease the symptoms.
The number of patients with implantable devices continues to grow. There are important aspects and difficulties in the perioperative management of these patients.
History of ICDs (Internal Cardiac Defibrillators)Jose Osorio
ICDs have been available since the 80s for the prevention of sudden cardiac death. The advancements are quite amazing, with a reduction in size from >250cc to less than 40cc, ease of implantation, safety and longevity.
Atrial Fibrillation Ablation - Improving Efficacy and Minimizing FluoroscopyJose Osorio
Atrial fibrillation ablation is a procedure performed to attempt to cure afib. It is traditionally performed using fluoroscopy (X-Ray) to guide, and exposure to radiation is a concern.
In order to minimize and sometimes completely avoid the use of radiation during the procedure newer techniques using the mapping systems have been developed.
This presentation shows some of the techniques I use to minimize fluoroscopy during ablation. This was presented at a course for electrophysiology fellows.
Internal Cardiac Defibrillators (ICDs) are devices implanted in patients that are at risk of dying suddenly. ICDs monitor the heart's rhythm and if a fatal arrhyhtmia is seen they can deliver shocks that can convert the patient back into normal rhythm and save a life.
Lean about ICDs, what they are and why they are used and how to life with one.
Atrial Fibrillation in Women - St Vincent's, Birmingham, ALJose Osorio
Go Red For Women - American Heart Association
Atrial fibrillation is a common condition in women, yet there are significant disparities in the treatment. Women with afib are more likely to have strokes and less likely to receive appropriate care.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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5. Atrial Fibrillation
Costs to the health care system
A LOT!!
Average hospital stay = 5 days
Mean cost of hospitalization = $18,800
Does not include:
Costs of cardioversions/ablations/surgery
Costs of drugs/side effects/monitoring
Costs of AF-induced strokes
Estimated US cost burden 15.7 billion
www.theafcenter.com
7.
Paroxysmal
◦ few seconds to days, then
stops on its own
◦ Typically younger, healthier
patients
Healthier
“Lone Afib”
Persistent
◦ does not stop by itself but will
stop with a medication or
cardioversion
Permanent
◦ present all the time and
cannot be fixed with
medication or cardioversion
More
Comorbidities
8. • Identify potential causes and
comorbidities
• Stroke Prevention
• Treating AF symptoms
www.theafcenter.com
11. Atrial Fibrillation
Obstructive Sleep Apnea
20 –
15 –
OSA
Cumulative
10 –
Frequency
of AF (%)
5–
No OSA
0–
0
1
2
3
4
5
6
No OSA
8
9
10
11
12
13
14
15
Years
Number at Risk
OSA
7
844
709
569
478
397
333
273
214
173
134
110
94
70
46
29
8
2,209
1,902
1,616
1,317
1,037
848
641
502
393
296
217
195
130
94
69
28
Cumulative frequency curves for incident atrial fibrillation (AF) for subjects < 65 years of age with and without obstructive sleep apnea (OSA)
during an average 4.7 years of follow-up. p = 0.002
Gami, et al. JACC 2007;49:565-71
www.theafcenter.com
12. • Identify potential causes and comorbidities
• Stroke Prevention
• Treating AF symptoms
www.theafcenter.com
13. Atrial Fibrillation and Strokes
• 5-fold higher risk of stroke
• Over 87% of strokes are thromboembolic
• >90% of thrombus originates in the Left Atrial
Appendage (LAA)
• Stroke is the number one cause of long-term disability
and the third leading cause of death in patients with AF
www.theafcenter.com
14. • 500,000 strokes/year in U.S.
• Up to 20% of ischemic strokes occur in
patients with atrial fibrillation
Percent of Total Strokes
Attributable to Atrial Fibrillation
35
30
25
20
%
15
10
5
0
50-59
60-69
Stroke 22(18), 1991
70-79
80-89
3000838-7
www.theafcenter.com
15.
>90% of strokes
in AF patients are
secondary to LAA
emboli
www.theafcenter.com
24. Atrial Fibrillation
Challenges in Stroke Prevention
• Warfarin
• Not always well-tolerated
• Less than 50% of patients eligible are being
• Time at therapeutic range - low
• Prevent Ischemic Strokes Cause Hemorrhagic Strokes
www.theafcenter.com
25. • Warfarin still cornerstone of therapy
• Assuming 51 ischemic strokes/1000 pt-yr
• Warfarin prevented 28 strokes at expense of 11
fatal bleeds
• Aspirin prevented 16 strokes at expense
of 6 fatal bleeds
• Warfarin
• 60-70% risk reduction vs no treatment
• 30-40% risk reduction vs aspirin
Cooper: Arch Int Med 166, 2006
Lip: Thromb Res 118, 2006
3000838-10
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29.
What can we offer patients that cannot take oral
anticoagulants?
Or do not want to take OACs
◦ Left Atrial Appendage Closure
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39. Device
Day 0
Day 2-14
Preimplant interval
Day 45
postimplant
Device subject takes
warfarin
Ongoing to 5 years
Device subject has ceased
warfarin
Control
Device subject gets implant
Randomize
Control subject takes warfarin
Day 0
Ongoing to 5 years
3000838-60
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40. • Primary Efficacy Endpoint
• All stroke: ischemic or hemorrhagic
• deficit with symptoms persisting more than 24 hours
•
•
or
• symptoms less than 24 hours confirmed by CT or
MRI
Cardiovascular and unexplained death: includes
sudden death, MI, CVA, cardiac arrhythmia and
heart failure
Systemic embolization
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42. Randomization allocation (2 device : 1 control)
Device
Cohort
900 pt-yr
Posterior
Probabilities
Control
Events
(no.)
Total
pt-yr
Rate
(95% CI)
Events
(no.)
Total
pt-yr
Rate
(95% CI)
Rel. Risk
(95% CI)
Noninferiority
Superiority
20
582.3
3.4
(2.1, 5.2)
16
318.0
5.0
(2.8, 7.6)
0.68
(0.37, 1.41)
0.998
0.837
Event-free
probability
1.0
ITT Cohort:
Non-inferiority criteria
met
WATCHMAN
0.9
Control
0.8
0
365
730
1,095
52
92
12
22
Days
244
463
147
270
3001664-2
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43.
Oral Anticoagulation is still considered first
line therapy
Lariat Device
◦ Reserved for patients with Contraindications to oral
anticoagulants
Watchman device
◦ Great results in patients that were eligible to take
warfarin
◦ May become first line therapy
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44.
What if my patient is back to Sinus Rhythm?
Does he still need anticoagulation?
What about after cardioversion?
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47.
AFFIRM has demonstrated that rate control
is an acceptable primary therapy in a
selected high-risk subgroup of AF patients
with minimal symptoms
Discontinuation of OAC in patients with
risk factors for stroke after CV or while on
rhythm control drugs is not appropriate
◦ Asymptomatic recurrences
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48. • Identify potential causes and comorbidities
• Stroke Prevention
• Treating AF symptoms
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53. 74 yo medically refractory AF, Echo – Normal
AA Rx - Verapamil, Rythmol, Betapace, Norpace
I
II
III
V1
RSPV
dist
RSPV
prox
*
LIPV
RA
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62. Lasso Guided PV Isolation
Before Ablation
During Ablation
A PV
A PV
After Ablation
I
PV-d
CS-p
CS-7/8
CS-5/6
CS-3/4
CS-d
HRA
PV-1/2
PV-2/3
PV-3/4
PV-4/5
PV-5/6
PV-6/7
PV-7/8
PV-8/9
PV-9/10
PV-10/1
100 ms
A
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63.
64. Pappone C, et,al.J Am Coll Cardiol. 2006 Dec 5;48(11):2340-7.
www.theafcenter.com
65. Freedom from AF Recurrence
P<0.001
Pappone C, J Am Coll Cardiol 2003
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66. QOL Following Ablation vs.
Medical Therapy for AF
Pappone C, et.al. JACC 42:185-97, 2003
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67. LV Function after AF Ablation
Patients with of Without CHF
Hsu LF, et.al., NEJM 351:2372-83, 2004
www.theafcenter.com
70.
Candidates for ablation
◦ Symptomatic atrial fibrillation despite medical
therapy
Paroxysmal Afib
easy to determine
Persistent Afib
Symptoms related to Afib?
Structural Heart Disease / LA dimension
Comorbidities
www.theafcenter.com
71.
AF is rarely life-threatening and is typically
recurrent
Treatment goals in symptomatic pts
◦ frequency, duration and severity of recurrences
◦ Reduce Stroke Risk
◦ Minimize risk of tachycardia induced
cardiomyopathy
www.theafcenter.com
72. Atrial Fibrillation
Highly Prevalent Condition
Treatment
◦ driven by symptoms
Atrial fibrillation ablation
◦
◦
◦
◦
Effective
Reduces or eliminates symptoms
Reduces risk of stroke
Significantly improves quality of life
www.theafcenter.com
205-939-0073
www.theafcenter.com
Editor's Notes
Arctic Front demonstrates a simple, straightforward approach to PVI which can be obtained in 4 steps. Step 1: Lead your guide wire/Achieve mapping catheter into the targeted veinStep 2: Inflate the Arctic Front balloon in the left atrium. Once inflated, position the balloon at the PV atrum.Step 3: To assure occlusion, inject dye into the targeted pulmonary vein to make sure the vein is completely occluded. Once assured, ablate the PV for 240 seconds (the dosage used in the STOP AF trial).Step 4: Assess pulmonary vein isolation with the Achieve mapping catheter
The majority of STOP AF investigators were first-time users of Arctic Front.As with any new technology or technique, there is a learning curve. Procedural effectiveness is linked to the number of procedures completed. This link is evident when displayed by quartiles with each quartile increasing its treatment success in the sequence those procedures were performed. Treatment success is inclusive of both acute procedural success and freedom from chronic treatment failure at 12 months.In the graph above, each bar represents approximately 41 cryoablation procedures (range 38-43). In the first bar, Quartile 1, there are 25 centers and 43 procedures. These procedures represent the 1st and 2nd Arctic Front procedures the 25 centers performed. The success rate for just these procedures was 56%.In the second bar, Quartile 2, there are 14 centers and 38 procedures. These procedures represent the 3rd – 5th Arctic Front procedures the 14 centers performed, for a success rate of 66%. Only 14/25 centers enrolled to this point. In the third bar there are 10 centers and 42 procedures. These procedures represent the 6 – 11th Arctic Front procedures those 10 centers performed, for a success rate of 69%.Finally, the last bar represents four centers and 40 procedures. These four centers performed at least 12 and up to 23 Arctic Front procedures. Only four centers enrolled this many ablation patients. The success rate for these specific procedures was 90%.