AF in 2014 Dr Stewart Healy

National Stroke Foundation report: Economic cost of AF in Australia AF: an epidemic? 1-2% Australian population have AF >50% are >75yo Costs $1.25 billion/yr Predominantly due to consequent stroke and HF National Stroke Foundation report: Economic cost of AF in Australia 2 2

Preventable If you have AF: 7 x more likely to have a stroke AF related stroke/impairment is more severe 3 x more likely to have heart failure 1 in every 6 strokes is AF related Preventable 3 3

AF: 3 key messages Stroke prevention Rate Control Rhythm Control (aim for SR) 4 4

Initial Evaluation 12 lead ECG/Holter - exclude atrial flutter and assess rate in AF and sinus. TTE- left atrial size is still the most predictable objective measurement for recurrence risk, assess LVEF Rule out associated conditions- TFT, UEC, CaMgPO4 Assess for modifiable risk factors- BP, OSA and ETOH excess Assess symptoms- some people have minimal symptoms through to fulminant heart failure Symptoms, age, LA size, LVEF and duration are the key determinants of management strategies

AF: Management current Stroke prevention ASA or warfarin, NOACs Rhythm control Flecainide, sotalol, amiodarone Cardioversion Pulmonary Vein Isolation Rate control AV node blockers- Digoxin, Beta-blockers and Ca2+ blockers “Pace and ablate” Aim for average HR 80bpm

AF: Management new Stroke prevention Rhythm control NOACs LAA occluding device (Watchman) Rhythm control Dronedarone, Vernakalant Catheter ablation, surgical ablation

Stroke Prevention CHADS/CHADSVASC Congestive Heart Failure= 1 Hypertension=1 Age (>75,)= 2 Diabetes= 1 Stroke=2 Vascular disease, female, age >65 for females 7 7

CHADS2 -> CHA2DS2VASc CHA2DS2-VASc Risk Score CHF or LVEF < 40% 1 Hypertension Age > 75 2 Diabetes Stroke/TIA/ Thromboembolism Vascular Disease Age 65 - 74 Female CHADS2 Risk Score CHF 1 Hypertension Age > 75 Diabetes Stroke or TIA 2 From ESC AF Guidelines http://www.escardio.org/guidelines-surveys/esc- guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf

Adjusted stroke rate %/year CHADS2 -> CHA2DS2VASc CHA2DS2- VASc score Patients (n = 7329) Adjusted stroke rate (%/year) 1 422 1.3 2 1230 2.2 3 1730 3.2 4 1718 4.0 5 1159 6.7 6 679 9.8 7 294 9.6 8 82 9 14 15.2 CHADS2 score Patients (n = 1733) Adjusted stroke rate %/year 120 1.9 1 463 2.8 2 523 4.0 3 337 5.9 4 220 8.5 5 65 12.5 6 18.2 From ESC AF Guidelines: http://www.escardio.org/guidelines-surveys/esc- guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf

Stroke Prevention Alternatives to warfarin: Clopidogrel Dabigatran Rivaroxaban Apixaban Edoxaban 7 7

NOACs Renal excretion- dose adjust No antidote Predictable dose response Less bleeding than Warfarin Superior to Warfarin Expensive Stable patients- leave on Warfarin eGFR below 30- Warfarin only

Rhythm Control Younger patients with symptoms Smaller LA size Prior to ablation/cardioversion Sotalol- watch for bradycardia, QT prolongation, don't use in very elderly or renal failure Flecainide- not to be used in LVF or CAD with ischaemia, watch QRS, mindful that can organise AF in atrial flutter thus use with an AV nodal blocking drug Amiodarone- liver, thyroid, lung, sun , neurological- 1 in 5 at 5 years with side effect but our most useful drug Cardioversion- to assess symptom status and propensity towards recurrence Lifestyle modification

Rate control Use in those who have either failed rhythm control or those who maintenance of sinus rhythm is futile. Assess with a 24 hour Holter and and EST (particularly those with exertional symptoms) Lenient rate control is acceptable if minimal symptoms and LVEF preserved Beta blockers- don’t be afraid to up-titrate the dose but do it slowly Ca2+ are useful Digoxin is losing favour- low dose is better and therapeutic levels on the lower end are preferred

Pace and Ablate Reserved for those who have failed rate control with ongoing symptoms, medication related side effects or LVF Elderly ( > 75) Bi-ventricular if LVEF is reduced Usually beneficial for symptomatic patients Does not change anticoagulation Pacemaker dependent Allows cessation of rhythm medications

Catheter ablation Monash Heart 2014 Radiofrequency Cryo-ablation Laser balloon Surgical 7 7

Catheter ablation for pAF Much more effective than drugs BUT procedural risk (2-5%) Most trial pts have Sx AF without SHD Consider in pts with ongoing Sx despite medication 10-30% repeat procedure Does not alter anticoagulation Mx plan Persistent AF - ablation still has a role but evidence based strategies for ablation techniques are currently lacking Several procedures necessary

What happens Day case General anaesthetic or light sedation INR 2.0 or cessation of NOACs- 36-48hrs prior Procedural time 1.5-2.5hrs End point is isolation of all pulmonary veins

Cryoablation

Cryoablation

Laser Balloon

Laser balloon

RF ablation

Inpatient AF management Rate control- AF does not acutely harm from a heart rate perspective unless sustained tachycardia Strokes do Always give anticoagulation prior to cardioversion but; Clexane is a dangerous drug

Post AF ablation issues Anticoagulation- Warfarin mostly given night of procedure Peri-procedural TIA/stroke Pericardial pain common Watch for signs of tamponade AF is still common after the procedure- not something we are concerned about generally and anti-arrhythmic meds are continued Phrenic nerve palsy- cryoablation Haemoptysis Atrio-oesophageal fistula- most feared complication and presents with pain on swallowing and fever Pulmonary vein stenosis