1. Atrial Fibrillation t

2. 1874 Alfred Vulpian- ‘Fremissement fibrillaire’ 1876 Carl Nothnagel- ‘Delerium Cordis’

3. 1906- Einthoven- 1 st EKG of afib 1909- Rothberger,Winterberg& Lewis- correlation between EKG and pulse

4. Atrial Fibrillation-Atrial Fibrillation- –Absent ‘P’ waves –Irregular atrial activity- ‘F’ waves Variable- amplitude, duration and morphologyVariable- amplitude, duration and morphology –Resultant irregular ventricular response –Impostures- atrial flutter and MAT

5. Classification First detected- single documented episode Recurrent- 2 or more episodes Paroxysmal- Spontaneous conversion (usually <7 days) Persistent- episodes are sustained (often >7 days) Permanent/Chronic- persistent (typically > 1year)

6. Etiologies Valvular Heart Disease- esp. Mitral Non valvular and Secondary causes –Cardiomyopathies (IDCM/NIDCM) –Hypertension –Post-CABG/Post operative state –Toxin- Thyrotoxicosis, ETOH –Pulmonary embolus/COPD –Hypoxia/Acidemia –Sinus Node dysfunction –Congenital Heart disease- WPW, ASD Lone Atrial Fibrillation –<12% without identifiable cause –Age <60

7. Conditions Allied with AF

8. Copyright restrictions may apply. Go, A. S. et al. JAMA 2001;285:2370-2375. Prevalence of Diagnosed Atrial Fibrillation Stratified by Age and Sex In General- <1% of Population < 60 yrs >6-8% of Population >80 yrs

9. Copyright restrictions may apply. Go, A. S. et al. JAMA 2001;285:2370-2375. Projected Number of Adults With Atrial Fibrillation in the United States Between 1995 and 2050

10. Concerns Thromboembolism Mortality Cardiomyopathy and CHF As well as –Known Knowns –Known Unknowns –Unknown Unknowns

11. Copyright ©2001 American Heart Association Fuster, V. et al. Circulation 2001;104:2118-2150 Relative risk of stroke and mortality in patients with AF compared with patients without AF Risk of CV ~5% per year with risk factors Annual CVA risk 23.5% for those aged 80 to 89 years

12. Copyright ©2005 American Heart Association Verma, A. et al. Circulation 2005;112:1214-1222 Kaplan-Meier curves describing survival in 46 984 post- coronary bypass surgery patients at the Cleveland Clinic from 1972 to 2000

13. AF and CVA Risk Factors CHADS2 –Hypertension- even a history thereof =1 –Diabetes =1 –Congestive heart failure =1 –Age >75 years –Prior TIA/CVA = 2 Others –Prior MI –Echo data- LV dysfunction (EF<35-40%), Left atrial enlargement –Some argue age >60 or 65 BF Gage et al. JAMA 2001 285: 2864-2870. Krahn AD et al. Am J Med. 1995;98:476-84. Atrial Fibrillations Investigators. Arch Intern Med. 1998;158:1316-20.

14. Risk for CVA: CHADS2 Score CVA risk/Yr 01.9% 12.8% 24.0% 35.9% 48.5% 512.5% 618.2% BF Gage et al. JAMA 2001 285: 2864-2870.

15. AF and Cardiomyopathy Rawles (Br Heart J 1990;63:157-61) -↓C.O. with HR>90 Tachycardia-induced Cardiomyopathy- may occur with heart rates ≥ 105-110 BPM over 10-14 days –Reversible with proper rate control –Symptoms vary between patients Rate Control –AFFIRM Resting HR ≤ 80 BPM 24 Hour Holter- Avg HR ≤ 100 BPM and no HR > 110% MTHR HR ≤ 110 BPM during 6 minute walk test Shinbane et al. J Am Coll Cardiol 1997;29:709-15. NHLBI AFFIRM investigators Am J. Cardiol 1997;79:1198-1202

16. AF in CHF: Prognostic Implications V-HeFT no effect of AF on mortality …but SOLVD found RR 1.34, p=0.002 (Cox) Framingham HR for death 1.6 in males; 2.7 females (Cox) V HeFT found no effect of AF on survival

17. Prevalence of AF and CHF 80% in “dropsy” –Mackenzie J. The Oxford medicine, 1920:387-492. Clinical Trial data 15-30% AF, higher with worse NYHA –Ehrlich, Nattel, and Hohnloser, JCE 2002 13: 399-405

18. AF and CHF- in sum AF and CHF appear to co-promote While treatment of LV dysfunction prevents AF, converse not clear (except in poorly rate-controlled subjects) Clinical trial data highly desirable –AF-CHF –Randomized study of non-pharmacologic treatment in subjects with LV dysfunction Circulation. 2008;118:S_827

19. Prevention of CHF by treatment of AF Ablate and pace –Uncontrolled studies show improvements in LV function –Controlled study- improved dyspnea and exercise tolerance but not LV function Circulation 1998;98:953-960 Mayo experience- does not alter prognosis –NEJM 344:1043-1051 Bi-V might be better –Eur Heart Journal 2002 23: 1780-1787

20. Can We fix it? Management Strategies –Rate Control Pharmacologic Non-Pharmacologic –Rhythm Control Anti-arrhythmics Surgical ‘correction’ Percutaneous ‘correction’ –Prevention

21. Rate vs. Rhythm Fuster et al. JACC.2006;48(4):e149-246 -No significant difference in mortality -Anticogulation is essential regardless of strategy

22. Fuster, V. et al. Circulation 2001;104:2118-2150 Pharmacological management of patients with newly discovered AF Assess for underlying disease: Echocardiogram Ischemic Heart diesase Endocrine disease OSA CVA Risk Stratify

23. Rate Control Strategy AV nodal blocking Agents –Beta-receptor antagonists –Non-dihydropyridine Calcium channel blockers –Digoxin-indirect via vagal effects Ablate and Pace

24. Rate control strategery Farshi et al. JACC 1999; 33(2): 304-310 Dig-βb

25. Mayo Ablate and pace experience NEJM 344:1043-1051

26. Rhythm Control Simplified Fuster et al. JACC.2006;48:854-906

27. Fuster, V. et al. Circulation 2001;104:2118-2150 Arrhythmia-free survival after electrical cardioversion in patients with persistent atrial fibrillation DCC- >87% successful in most patients Only 25-35% of patients will be in sinus rhythm at one year Kastor, J.A. Arrhythmias, Second Edition W.B. Saunders Co.. 2000: pp79-81

28. Anti-arrhythmics Fuster et al. JACC.2006;48(4):e149-246

29. Dronedarone -Contraindicated in Class IV CHF

30. Roy, D. et al. N Engl J Med 2000;342:913-920 Percentage of Patients Remaining Free of Recurrence of Atrial Fibrillation 18% of the patients receiving amiodarone and 11% of patients receiving sotalol or propafenone had to discontinue therapy because of adverse effects

31. RACE II

33. Surgical Modification Cox-Maze Several Modifications Variable results –? Data Still considered the ‘Gold Standard’

34. Dr. Cox?

35. Evolution of percutaneous AF ablation 1994 John Swartz first reports endocardial maze procedure 1998 Haissaguerre isolates pulmonary vein “culprit” 1999-2003 more PVs, more foci 2003 Pappone anatomic approach 2004 Morady Need to isolate 4/4 veins 2004 Pappone ablate vagal efferent Marine, Prog Card Disease 2005

36. Pulmonary Vein Isolation

37. Alternative approach

38. Success rates for ablation outside the PV “success rates 2-3 times that of antiarrhythmic medications” Verma Circ 2005

39. Complication in Modern Series JACC 2009;53:1798-803 -45 K procedures, 32.5 K patients, 162 centers -Between 1995 and 2006 -0.98 in 1000 mortality

40. Cost in Medicare Dollars -50% unsuccessful

41. Theory: Prevention Paroxysmal AF Persistent AF years Hypertension Sleep apnea RAAS activation Fibrosis Diastolic Dysfunction Altered substrate Altered electrophysiology Permanent AF

43. Non-Antiarrhythmic Agents for Afib prevention

44. Summary Highly prevalent condition with significant associated morbidity and mortality –Driven mostly by thromboembolic events Decision to pursue rhythm control based on patient symptoms Rhythm control –Anti-arrhythmics still 1 st line –Ablative or surgical therapy- case by case