1. AF in 2014
Dr Stewart Healy

2. 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

3. 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

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

5. 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

7. 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

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

9. 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

10. CHADS2 -> CHA2DS2VASc CHA2DS2-VASc Risk Score CHF or LVEF < 40%1
Hypertension
Age > 75 2
Diabetes
Stroke/TIA/ Thromboembolism
Vascular Disease
Age
Female
CHADS2 Risk
Score
CHF 1
Hypertension
Age > 75
Diabetes
Stroke or TIA 2
From ESC AF Guidelines
guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf

11. 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: guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf

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

14. 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

19. 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

20. 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

21. 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

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

23. 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

24. What happens Day case General anaesthetic or light sedation
INR 2.0 or cessation of NOACs hrs prior
Procedural time hrs
End point is isolation of all pulmonary veins

29. Cryoablation

30. Cryoablation

31. Laser Balloon

32. Laser balloon

33. RF ablation

34. 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

35. 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