Afib
Afib
Afib
2016 Update
Evaluation and
Management
Hutton P. Brantley, DO, FACC
Objectives
• Provide an overview of the pathophysiology,
diagnosis, classification schemes, and signs and
symptoms of AF.
• Discuss electrical and chemical cardioversion in
AF.
• Review rate control, rhythm control, and
anticoagulation as treatments for AF.
• Develop an individualized pharmacotherapy and
monitoring plan for the management of AF as
dictated by patient‐specific parameters.
Agenda
• Definitions and Pathophysiology
– Mechanisms
• Clinical Evaluation
• Prevention of Thromboembolism
– Risk Stratification Schemes
– Antithrombotic and Nonpharmacological options
• Rate control
– Pharm agents/ AV Node Ablation
• Rhythm control
– Cardioversion (electrical and pharm)
• AF Catheter Ablation
• Specific groups
Atrial Fibrillation ‐Definition
• Supraventricular tachyarrhythmia with
uncoordinated atrial activation and
consequently ineffective atrial contraction
• Characteristic ECG
– Irregular R‐R intervals
– Absence of distinct repeating P waves
– Irregular atrial activity
Diagnosis
Symptoms
• No symptoms
• Fatigue – most common
• Palpitations
• Dyspnea
• Hypotension
• Syncope
Pathophysiology
Pathophysiology
Classification
Classification and Patterns of AF
Fuster et al. Circulation 2006
Lone AF
• 30% to 45% of paroxysmal AF cases and 20%
to 25% of persistent AF cases occur in young
patients without an underlying medical
condition
• Lone AF may be a familial arrhythmia, or a
causal underlying condition may appear over
time.
Risk Factors
Reversible Permanent
• Holiday heart syndrome • Mitral valve disease
• Surgery • CHF
• Electrocution • HTN
• MI • LVH
• Myocarditis • Cardiomyopathy
• PE
• Hyperthyroidism
• Electrolyte abnormality
An 82 year old man is in your office for an
annual Medicare physical. What is the chance he
has atrial fibrillation?
1. 1%
2. 5%
3. 10%
4. 25%
Prevalence of Diagnosed AF
Stratified by Age and Sex
Go AS, JAMA. 2001 May 9;285(18):2370‐5. Pub Med PMID: 11343485
A 46 year old male patient is in for an annual
physical exam. What is his lifetime risk of
developing AF?
1. 1%
2. 5%
3. 10%
4. 25%
Incidence of AF
Lifetime Risk for AF at Selected Index Ages by Sex
1 in 4
Men & women Lifetime risk if
>40 Years currently free
will develop AF of AF
Lloyd‐Jones DM, et al. Circulation. 2004 Aug 31;110(9):1042‐6. Pub Med PMID: 15313941.
Management
• Prevention of TE complications
• Restoration of sinus rhythm
• Controlling ventricular rate in AF
STROKE PREVENTION
68 year old female with atrial fibrillation and no
other co‐morbidities. How would you classify
her stroke risk?
1. Low
2. Moderate
3. High
Scoring Systems in Stroke Risk
• A variety of systems have been published
– Outlined on next slide
• All use selected clinical characteristics to
predict the risk of stroke
• Most widely used is the CHADS2 score
• All scores provide a rough estimate of risk of
thrombosis in a population at similar risk as
patient being reviewed
CHADS2: Risk of Stroke
National Registry of Atrial Fibrillation Participants (NRAF)
NRAF Crude NRAF Adjusted
CHADS2 # Patients # Strokes Stroke Rate per Stroke Rate
Score (n = 1733) (n = 94) 100 Patient‐yrs (95% CI)†
0 120 2 1.2 1.9 (1.2‐3.0)
1 463 17 2.8 2.8 (2.0‐3.8)
2 523 23 3.6 4.0 (3.1‐5.1)
3 337 25 6.4 5.9 (4.6‐7.3)
4 220 19 8.0 8.5 (6.3‐11.1)
5 65 6 7.7 12.5 (8.2‐17.5)
6 5 2 44.0 18.2 (10.5‐27.4)
Scoring:
1 point: Congestive heart failure, HTN, < 75 years, and DM
2 points: Stroke history or transient ischemic attack
† Expected stroke rate per 100 pt‐yrs from the exponential survival model, assuming aspirin not taken
Risk Factor Score
Congestive heart failure/LV dysfunction 1
Hypertension 1
Age ≥ 75 y 2
Diabetes mellitus 1
Stroke/TIA/TE 2
Vascular disease 1
(prior myocardial infarction, peripheral artery disease, or aortic plaque)
Age 65‐74 y 1
Sex category 1
(i.e. female gender)
LV = left ventricular; TE = thromboembolism
TE Rate During 1 yr,
CHA2DS2‐ #TE TE Rate During 1 Adjusted for
VASc Score # Events yr (95% CI) Aspirin RX
0 103 0 0% (0‐0) 0%
1 162 1 0.6% (0.0‐3.4) 0.7%
2 184 3 1.6% (0.3‐4.7) 1.9%
3 203 8 3.9% (1.7‐7.6) 4.7%
4 208 4 1.9% (0.5‐4.9) 2.3%
5 95 3 3.2% (0.7‐9.0) 3.9%
6 57 2 3.6% (0.4‐12.3) 4.5%
7 25 2 8.0% (1.0‐26.0) 10.1%
8 9 1 11.1% (0.3‐48.3) 14.2%
9 1 1 100% (2.5‐100) 100%
Total 1,084 25 P Value for trend 0.003
1.Gage BF, et al. Am Heart J. 2006 Mar;151(3):713‐9. PMID: 16504638. Pub Med PMID:16504638.
2.Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. Chest. 2010 Nov;138(5):1093‐100. PMID:20299623.
3.Fang MC, et al. J Am Coll Cardiol. 2011 Jul 19;58(4):395‐401. Pub Med PMID:21757117.
Bleeding Risk Scores in AF
ATRIA HAS-BLED HEMORR2HAGES
Clinically Relevant Major
Scheme All Patients Bleeding Bleeding
HEMORR2HAGES
Low (≤1) Risk 1,738 (76.6) 182 (10.5) 25 (1.4)
Intermediate Risk (2–3) 517 (22.8) 63 (12.2) 13 (2.5)
High Risk (>3) 13 (0.5) 3 (23.1) 1 (7.7)
TOTAL 2,268 248 (10.9) 39 (1.7)
HAS‐BLED
Low Risk (<3) 1,739 (75.9) 159 (9.1) 22 (1.3)
High Risk (≥3) 553 (24.1) 92 (16.6) 17 (3.1)
TOTAL 2,292 251 (11.0) 39 (1.7)
ATRIA
Low Risk (<4) 2,038 (90) 220 (10.8) 31 (1.5)
Intermediate Risk (4) 102 (4.4) 13 (12.7) 3 (2.9)
High Risk (>4) 128 (5.6) 18 (14.1) 5 (3.9)
TOTAL 2,268 248 (10.9) 39 (1.7)
All cause stroke/SEE
Ischemic and unspecified stroke
Hemorrhagic stroke
Connolly S et al. NEJM 2009; Patel M et al NEJM 2011; Granger CB et al NEJM 2011
Risk‐Based Antithrombotic Therapy
Recommendations COR LOE
AT therapy based on shared decision making, discussion of risk of I C
stroke and bleeding, and patient’s preferences
Selection of therapy based on risk of thromboembolism I B
CHA2DS2‐VASc recommended to assess stroke risk I B
Warfarin recommended for mechanical heart valves I B
With Prior Stroke, TIA, or CHA2DS2‐
VASc ≥2, OAC recommended
Recommendations COR LOE
Warfarin I C
Dabigatran, rivaroxaban, or apixaban I B
With warfarin, determine INR at least weekly during initiation of I B
therapy and monthly when stable
Direct thrombin or factor 10a inhibitor recommended if unable to I B
maintain therapeutic INR
Evaluate renal function before initiation of direct thrombin or factor I C
10a inhibitors
For atrial flutter, anti thrombotic therapy is recommended as for AFib I C
For patients without mechanical heart valves, bridging therapy I C
decision should balance stroke and bleeding risks against duration of
time the patient would not be anticoagulated
OAC Recommendations
Recommendations COR LOE
For nonvalvular AF and score of 0 it is reasonable to omit anti IIa B
thrombotic therapy
With nonvalvular AF and score of 1, no anti thrombotic therapy or IIb C
treatment with oral anticoagulants or aspirin may be considered
After coronary revascularization, it may be reasonable to use IIb C
clopidogrel concurrently with oral anticoagulants but without aspirin
OAC Recommendations
Recommendations COR LOE
Direct thrombin inhibitor and factor Xa inhibitor not recommend in III: No C
patient’s with atrial fibrillation and end‐stage renal disease or on Benefit
dialysis because of lack of evidence from clinical trials regarding the
balance of risks and benefits
Direct thrombin inhibitor should not be used with a mechanical heart III:Harm B
valve
RHYTHM AND RATE CONTROL
Rate or Rhythm Control
Rate vs Rhythm Control
AF begets AF
AFFIRM Investigators. N Engl J Med 2002
AFFIRM – Cause‐Specific Mortality
Steinberg et al. Circulation 2004
No survival benefit associated with
rhythm‐control strategy
• STAF (n = 200)
• PIAF (n = 252)
• HOT CAFÉ (n = 205)
• RACE (n = 522)
• AFFIRM ( n = 4060)
Why hasn’t rhythm control worked in
trials?
• Drugs used in trials don’t guarantee rhythm
control
• Toxicity of drugs contribute to lack of benefit
• AF may be a marker of poor prognosis, in
which the primary problem is poor LV
function, neurohormonal activation, or
inflammation, with no independent effect of
AF on the outcome
Amiodarone side effects
AFFIRM: Prevalence of Sinus Rhythm
at Follow‐up
If drugs don’t work, will ablation?
• Continues to evolve rapidly with
improvements in the efficacy and safety of
procedure
• Efficacy for maintaining SR is superior to
current AAD in selected patient pop.
– Younger, no structural HD, experienced center
• Evidence insufficient if it reduces all cause
mortality, stroke, and HF.
– CABANA, EAST
Factors to consider
• Type of AF (parox vs persistent)
• Age
• Degree of symptoms
• SHD
• Candidacy for alternative agents
• Likelihood of complications
• Patient preference
AF Catheter Ablation Guidelines
AF catheter ablation is useful for SYMPTOMATIC PAROXYSMAL AF I A
refractory or intolerant to AT LEAST 1 Class I or III AAD when a rhythm
control strategy is desired
AF catheter is reasonable for some patients with SYMPTOMATIC IIa A
PERSISTENT AF refractory or intolerant to at least Class I or III AAA
when a rhythm control strategy is desired
AF catheter ablation is reasonable for SYMPTOMATIC PAROX AF IIa B
before therapeutic trial of AAD
Should not be performed in patients who cannot be treated with OAC III C
during and after the procedure
AF catheter ablation should not be performed for the sole intent of III C
obviating the need for OAC
Specific Patient Groups and AF
• ACS
– 10‐20% ACS patients
• Hyperthyroidism
• Acute noncardiac illness
– Elevated catecholamine state
• Pulmonary disease
• WPW/Pre‐excitation syndromes
Nonpharmacologic Stroke Prevention
• Percutaneous LAA occluders
– WATCHMAN
• Cardiac surgery –LAA Occlusion/Excision
– IIB during cardiac surgery
From: Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation: A Randomized Clinical
Trial
JAMA. 2014;312(19):1988-1998. doi:10.1001/jama.2014.15192
Figure Legend:
Kaplan-Meier Curves for the Primary Efficacy and Safety End PointsThe primary efficacy outcome (A) was stroke, systemic
embolization, or cardiovascular death. The primary safety outcome (B) was a composite of major bleeding events and procedure-
related complications. Incident probabilities for the intention-to-treat analysis are shown. HR indicates hazard ratio.