1. MANAGEMENT OF ATRIAL FIBRILLATION VINOD G V

2. Definitions Paroxysmal AF - self-terminating, usually within 48 h, may continue for up to 7 days. Persistent AF - when an AF episode either lasts longer than 7 days or requires termination by cardioversion. Long-standing persistent AF has lasted for ≥1 year when it is decided to adopt a rhythm control strategy. Permanent AF-DC version failed or not attempted Recurrent AF-has had 2 or more episodes

3. “lone AF” generally applies to young individuals under 60 y of age without clinical or echocardiographic evidence of cardiopulmonary disease including hypertension. have a favorable prognosis with respect to thromboembolism and mortality.

5. Haemodynamics Loss of atrial contraction A rapid ventricular rate An irregular ventricular rhythm Loss of mechanical AV synchrony affects ventricular filling esp. when left ventricle has reduced compliance.

6. 3 objectives Rate control prevention of thromboembolism correction of the rhythm disturbance,

7.  Type and duration of AF  Severity and type of symptoms  Associated cardiovascular disease  Patient Age  Associated medical conditions  Pharmacological and nonpharmacological therapeutic options.

8. Rapid ventricular rate produce symptoms Tachycardia related cardiomyopathy

9. Rate control Strict rate control: Resting HR -60-80 Moderate exercise 90-110 Lenient HR Resting HR <100 RACE II (RAte Control Efficacy in permanent atrial fibrillation) trial did not identify a benefit of stringent rate control over lenient rate control therapy in 614 patients

11. Primary Outcomes Cardiac death CHF Stroke Systemic embolism Major bleed Syncope Sust VT Cardiac arrest Life threat compl of antiarrhythmic Pacemaker Secondary Outcomes Symptoms

16. Beta-Blockers useful in the presence of high adrenergic tone or symptomatic myocardial ischaemia Non dihydropyridine CCB-Diltiazem,verapamil Digoxin-effective at rest,not during exercise

17. Rhythm control

18. Theoretical Benefit of Rhythm Control Improved hemodynamics Relief of symptoms Improved exercise tolerance Reduced risk of stroke Avoidance of anticoagulants

19. Rhythm control Pharmacological Non pharmacological Cardioversion Catheter Ablation

20. Cardioversion in AF Pharmacological Electrical cardioversion

21. DC Cardioversion Delivery of an electric shock synchronised with the intrinsic activity of heart by sensing the R wave Successful cardioversion depends on Duration of AF Current density delivered to atrial myocardium

25. Joglar JA et al Am J Cardio 2000

26. Mittal S et al Ciculation 2000

27. Elhendy A et al Am J Cardio 2002

28. Pharmacological cardioversion Simple Less efficaious More effective in AF <7 day duration Problems of drug toxicity

29. AF lasting <1 wk – cardioversion -using oral flecainide, propafenone, dofetilide, and intravenous ibutilide. For longer duration- iv dofetilide( also amiodarone and ibutilide may be useful) Single oral dose of propafenone or flecainide – in recent onset AF (pill in the pocket)

30. 2 strategies Oral warfarin with a therapeutic INR (2–3) for 3 to 4 weeks before cardioversion followed by continued warfarin thereafter Transesophageal echocardiography (TEE) and heparin immediately before cardioversion followed by oral warfarin thereafter. Left atria – stunning effect. So anticoagulation is to be continued for 4 wks

31. AF upto 7 days

32. AF >7 days

33. Pharmacological Rhytm control

34. Major Trials Comparing Rhythm Strategy and Rate Strategy Major trials include: – AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management ) – RACE (rate control versus electrical cardioversion) – PIAF (pharmacological intervention in AF) – AF-CHF Major overall findings : – Rhythm-control strategy was not superior to rate-control strategy in terms of morbidity/mortality – Appropriate choice of therapy should be based on each patient’s symptoms and disease – rate control, prevention of thromboembolism, and correction of the rhythm disturbance - these strategies are not mutually exclusive

39. AFFIRM : 5 Year Outcomes SurvivalRhythm controlRate control 1yr96 3yr8789 5yr7679 NO DIFFERENCE:Death, major bleed,disabling stroke,cardiac arrest Sinus rhythm maintained in only 63% of rhythm control group

40. AFFIRM Trial No survival advantage to rhythm control. Rhythm control patients were more likely to be hospitilized with adverse drug effects. Both groups had similar stroke risk (1% per yr) –Majority of strokes when warfarin stopped or INR subtherapeutic –Warfarin required long term even if sinus rhythm restored Torsades, bradycardic arrest more common with rhythm control.

41. Attempts at restoration of sinus rhythm not always successful –AFFIRM Trial: only 63% of “rhythm control” group were in sinus rhythm –Antiarrhythmics used to maintain sinus rhythm associated with a 25-50% annual failure rate. Long term anticoagulation not mandated in the “rhythm control” group –Those in afib at risk for stroke Medications used to maintain sinus rhythm risk of proarrhythmia and other toxicity

42. Vernakalant Acts preferentially in atria Blocking several ion channels Prolongation of atrial refractoriness Rate dependent slowing of atrial conduction Little impact on ventricular repolarization Pharmacological cardioversion of AF <7 days or <3days for patients after cardiac surgery

43. AVRO Double-blind,active-controlLed -i.v. amiodarone N=232 Vernakalant n = 116, Amiodarone n = 116 Hypertension(71.6%) ischaemic heart disease(22.4%) myocardial infarction (8.2%) heartfailure(19.8%)(NYHA I- 45.7%, NYHA54.3%) valvular heart disease, 6.9% AF 3–48 h (median 17.7 h) Time to conversion 11m Conversion to SR- 51.7% vs. 5.2% P <0.0001 Reduction in symptoms at 2 h reported by 53.4% patients in the vernakalant groupvs. 32.8% in the Amiodarone group P = 0.0012

44. “Pill in the Pocket” strategy Preferred in – Paroxysmal AF with no structural heart disease – Self administration of a single oral dose of drug shortly after the start of palpitations – Decrease hospital visits Propafenone 450-600mg Flecainide 200-300mg

45. Anti-arrhythmic drugs for maintaining sinus rhythm

46. Selection of specific agent depends on underlying cardiac disease

49. CATHETER ABLATION IN AF

50. Factors Factors that trigger Factors that perpetuate Triggering foci of rapidly firing cells within the sleeve of atrial myocytes extending into the pulmonary veins - shown to be the underlying mechanism of most paroxysmal AF

51. When to consider ablation? Antiarrhythmic therapy ineffective Antiarrhythmic therapy not tolerated Symptomatic afib

52. The stage of atrial disease ( AF type, LA size, AF history) The presence and severity of underlying cardiovascular disease Potential treatment alternatives (antiarrhythmic drugs, rate control) Patient preference

53. Anatomic ablation Electrogram guided ablation

54. Anatomic Carto Map of Lett atrium ablation points

58. Ablation may be a first strategy Patient very symptomatic in AF and refuses antiarrhythmic drug therapy Young patient whose only effective antiarrhythmic drug is amiodarone Patient with significant bradycardia for whom antiarrhythmic drug therapy will require pacemaker

60. Results Difficult to interpret –Success rate Optimal patient: –single procedure 60 - 80% –Multiple procedures 80 – 90% –Poor patient (eg 3 years persistent afib, sig enlarged LA –Best success with paroxysmal and healthy heart –Least success with chronic and diseased left atrium –May recur despite initial success –May recur without symptoms Ultimate goal: Rhythm control without toxic antiarrhythmics

61. Complication rate 1-5% –Tamponade – atrial perforation –TIA, stroke –Major bleed –Creation of atrial flutter (up to 8%) –Vascular access complications –Pulmonary vein stenosis (lower incidence than initial) –Aorto-esophageal fistula –Fatal 1/1000 Lengthy procedure –4-5 hours

65. Risk factors for recurrence of afib Long-term persistent afib Valvular heart disease Dilated cardiomyopathy

67. Anti Thrombotic therapy

68. Risk stratification CHADS2 –Congestive heart failure - 1pt –Hypertension - 1pt –Age > 75 - 1 pt –Diabetes - 1pt –Stroke or TIA - 2 pts –0 points – low risk (1.2-3.0 strokes per 100 patient years) –1point– moderate risk (2.8-4.0 strokes per 100 patient years) –> 2 points – high risk (5.9-18.2 strokes per 100 patient years)

71. CHA 2 DS 2 -VAS C

75. Anticoagulation strategy CHADS2 score 0 No anti thrombotic therapy CHADS2 score 1 Aspirin 75-325 mg daily Oral anti coagulation CHADS2 score 2 Oral anti coagulation

76. Anti thrombotic therapy VKA eg: warfarin Antiplatelets eg aspirin,clopidogrel Newer oral anti coagulants Direct thrombin inhibitor-Dabigatran Fa Xa inhibitors-Apixaban,Rivaroxaban

77. Warfarin Effective Reversible Inexpensive Slow onset of action Regular monitoring Food interraction Medication interraction Difficult titration-regular dose adjustments

81. Aspirin

83. Clopidogrel + Aspirin ?

84. Aspirin: stroke 3.4% per year major bleed 1.27% per year Aspirin + clopidogrel: stroke 2.4% per year major bleed 2.0% per year

85. New anticoagulants Short half life – less bleeding Lack of need for routine monitoring Generally safer than warfarin –No antidote Cost of medication –Overall cost of care

86. Apixaban (Aristotle trial) Twice daily: 5mg BD Less hemorrhagic stroke than warfarin Similar reduction in ischemic stroke Less bleeding than warfarin Lower overall mortality No routine lab testing No reversal –Half life 8-15 hours

87. Dabigatran(RELY trial) Dabigatran 110 mg twice daily –Equal to warfarin in stroke prevention Warfarin 1.69%/yr – dabigatran (110mg) 1.53%/yr –Less bleeding than warfarin Warfarin 3.36%/year – dabigatran (110mg) 2.71%/yr Dabigatran 150 mg twice daily –More effective than warfarin in stroke prevention Dabigatran (150mg) 1.11%/yr –Equivalent bleeding to warfarin less hemorrhagic stroke than warfarin

88. Rivaroxaban (Rocket AF trial) Once daily: 20 mg Less hemorrhagic stroke than warfarin Similar reduction in ischemic stroke Less bleeding than warfarin No routine lab testing No reversal –Half life 5-9 hours Discontinuation : increased stroke

89. CHADS2 score includes all except 1.TIA 2.Age > 60 yrs 3.DM 4.Congestive heart failure

90. 55 yr old man with AF, no h/o HTN,DM,no structural heart disease TRUE regarding antithrombotic therapy 1.Aspirin 150 mg OD 2.Warfarin 2mg 3.Dabigatran 150 mg BD 4.No antithrombotic therapy needed

91. 30 yr old patient presented to emergency department with 2hr h/o palpitation,ECG showing wide complex irregular tachycardia rate 200/min preferred method of treatment 1.IV Verapamil 2.IV Diltiazem 3.IV Digoxin 4.IV Procainamide

92. Drug used in “pill in the pocket strategy” 1.Sotalol 2.Propafenone 3.Ibutalide 4.procainamide

93. True about Dabigatran except 1.RE-LY trial evaluated dabigatran 2.Two doses were evaluated in RE-LY trial 3.Rate of haemorragic stroke more compared to warfarin 4.Dose adjustment needed in CKD

94. CHA 2 DS 2 VASc score includes all except 1.Age 65-74 yrs 2.Male sex 3.Atherosclerotic plaque in aorta 4.HTN

95. Drug prefered for maintainance of sinus rhythm in structurally abnormal heart is 1.Sotalol 2.Betablockers 3.Amiodarone 4.Ibutalide

96. Rivaroxaban true except 1.Rivaroxaban better than warfarin in reducing stroke in AF 2.20 mg twice daily 3.Less haemorrhage than warfarin 4.Evaluated in ROCKET AF trial

97. VERNAKALANT all are true except 1.Acts preferentially in atria 2.Causes significant QT prolongation 3.Used in post operative AF conversion 4.Contraindicated in heart failure

98. Apixaban TRUE EXCEPT 1.Direct thrombin inhibitor 2.Evaluated in ARISTOTLE trial 3.Cause less haemorrhage than warfarin 4.Non inferior to warfarin in stroke prevention