Management of atrial fibrillation

Management of atrial fibrillation

MANAGEMENT OF ATRIAL FIBRILLATION Mary N. Healy, MS, ARNP-BC Heart & Vascular Center of Sarasota OBJECTIVES 1. Define the difference between paroxysmal and 2. 3. 4.

5. persistent Atrial Fibrillation State the CVA risk per year of a 68 yr old female with hypertension that presents with new onset paroxysmal atrial fibrillation Discuss two reasons to pursue rhythm control over rate control Name 2 patient conditions in which warfarin is the only safe consideration for thromboembolic events in AF Idenitify one drug that can be used for pharmacologic

cardioversion to restore normal sinus rhythm Pearls of AF Management Address underlying triggers Hyperthyroidism, hypertension, obesity, alcohol, OSA, U/LRI Everyone needs rate control (to improve symptoms & prevent tachycardia related cardiomyopathy) <80 at rest and <110 most simple activity-assess with Holter monitor

Use beta blocker if pt has CHF or CAD Use non-dihydropyridine CCB in those with COPD or asthma If more rate control needed, add digoxin Rate vs Rhythm control AFFIRM and RACE trials showed that mortality rates were slightly better with rate control. However the exceptions are: <65, those with CHF, those with persistent symptoms despite rate control Pearls of AF Management Drugs or Ablation for Rhythm Control

Opportunity for shared decision-making. Ablation more successful, but is associated with more risk. If drugs not successful, follow with ablation. Amiodarone has benefit of both rate and rhythm control, but has serious potential side effects When to Anticoagulate and What Drug to Use Make life easy, download an app to your phone to figure CHA2DS2VASc & HAS-BLED score 8

CHA2DS2VASc of 2 or more and HAS-BLED score of < or = 3 warrant anticoagulation with warfarin or a novel oral anticoagulant APP for Thromboembolic Risk Pearls of AF Management Use warfarin in those with valve replacement, mitral stenosis, end- stage kidney disease or on dialysis If you use a novel anti-coagulant with chronic kidney disease, the dose needs to be reduced

In the elderly with the novel agents, periodically re-evaluate renal function do determine if dosage changes should be made Dual antiplatelet therapy (aspirin + clopidogrel) is no longer recommended due to risk of bleeding INTRODUCTION TO AF Incidence/Scope of the Problem Mechanisms causing AF are multi-factoral, making it a complex and many times difficult for

practitioners to manage. Symptoms range from non-existent to severe. Frequent hospitalizations, thromboembolic events, hemodynamic disruptions result in significant morbidity and mortality. Scope of Problem Stroke/CHF/Dementia Risk 5 fold increase risk of stroke, and stroke risk increases with age

AF related stroke is likely to be more severe than non-AF stroke 3 fold risk of CHF 2 fold increased risk of dementia as well as death Scope of Problem Costs Hospitalizations with AF as the primary diagnosis accounts for >467K admits in the US. >100K deaths/year

Pts. with AF are twice as likely to be hospitalized & 3 times more likely to have multiple hospitalizations Treating pts. with AF adds ~$26 billion to the US healthcare bill annually. Affects 6.1 million American adults and is expected to double in the next 25 years. Definition of Atrial Fibrillation AF is a supraventricular tachyarrhythmia with

uncoordinated and ineffective atrial contraction Characterized by; Irregular R-R intervals Absence of P waves Irregular atrial activity (fibrillation waves) Mechanisms of Atrial Fibrillation Patient Assessment Triggers of AF

Risk Factors Hyperthyroid Increasing Age ETOH use European ancestry Recent Pulm. Infection

FH/Genetics OSA LVH/LAE/Mitral Valve Dis. Smoking CHF

Immediate post-surgery DM Inordinate Stress MI Electrolyte Imbalance HTN

Obesity Patient Assessment Chief Complaint May be asymptomatic

especially if >65 yr. Fatigue Palpitations SOB Dizziness Syncope Frequent urination Physical Findings

Irregular pulse Irregular JVP Variation of intensity of S1 May also find: CHF symptoms Valvular murmur of MR or MS Suggested Treatment Algorithm

REDUCING THROMBOTIC RISK Priority #1 in AF/Reduce Embolic Risk Therapy based on For pts with artificial shared decision making Base on risk of TE risk regardless of pattern

(paroxysmal, permanent, etc) In non-valvular AF, CHA2DS2-VASc is recommended assessment of CVA risk heart valves, warfarin is recommended. Balancing the Risks and Benefits

Non-valvular AF increases CVA risk x5. AF in presence of mitral stenosis, increases CVA risk x 20 over those in NSR 90% of strokes from AF are caused by a clot in the left atrial appendage

Antithrombotic Options Prevent strokes and systemic emboli in part by reducing the formation of platelet rich or thrombotic clots in the LA or LA appendage Clinical Trials have looked at Warfarin vs aspirin; aspirin with warfarin or clopidogrel (Plavix) and aspirin; warfarin vs. aspirin and clopidogrel; warfarin vs. direct thrombin inhibitors (dabigatran-Pradaxa); warfarin vs. Xa inhibitors (Apixaban-Eliquis & rivaroxaban-Xarelto)

Coag Cascade and Antithrombotics Warfarin Vitamin K antagonist (VKA) in use since the 1950s. Works on multiple sites of the coagulation cascade- Factor IX, VII, X, II Pros Inexpensive, available as generic When INR therapeutic, significant risk reduction in stroke risk

Cons Narrow therapeutic window Increased risk of serious bleeding, including brain Interaction with other drugs Effects of alterations in diet Freq. blood tests- therapeutic range achieved only ~55% of time Dabigatran Direct Thrombin Inhibitor 150mg BID superior to warfarin in stroke, systemic

embolism. Hemorrhagic strokes, less, but major bleedsnon inferior to warfarin. Average CHADS score 2.1 Also available 75mg BID for CrCl 15-30 mL/min-this dose never studied. Pros No blood testing No drug or dietary interaction Cons BID dosing High price

Rivaroxaban Direct factor Xa inhibitor (excreted by kidneys) Studied older pts and mean CHADS score was 3.47 Non-inferior to warfarin in stroke risk and major bleeding, but did have less fatal bleeding and less brain bleeds. Dose is 20mg daily with evening meal for CrCl>50mL/min or 15mg for CrCl 30-49mL/min Pros No blood testing Once daily dosing (though is with evening meal)

Minimal drug and no dietary interactions Cons Expensive Apixaban Direct factor Xa inhibitor (eliminated hepatically and highly protein bound) Significantly better than warfarin in reducing strokes (both ischemic and hemorrhagic), systemic emboli and major

bleed events. Fewer deaths than warfarin Average CHADS 2.1, mean age 70 Dosing-5mg bid unless meet two of the following: age > or = to 80, weight < or = to 60Kg, serum creatinine >=1.5mg/ dL, then 2.5mg bid Pros and Cons Similar to the other novel anticoagulants General considerations in choosing anticoagulants If stable on warfarin

Reversing warfarin: and pt is happy with blood testing, etc, no need to change Medicare pts are covered if they wish, to do home monitoring checks-may increase the time in therapeutic

range Aquamephyton (Vitamin K) usually po, is available IV, takes several hours to reverse FFP infusion, time to reverse Anticoag Considerations, contd If warfarin chosen as

Novel anticoagulants are anticoagulant, it will take AT LEAST 5 days, and probably longer to achieve therapeutic INR, strongly consider using subq heparin, or enoxaparin to bridge until therapeutic

Pt education required to counsel on testing, drug & food interactions approved in AF for nonvalvular AF. Also approved for other indications, DVT, PE, but NOT FOR METAL VALVES Rapid onset and offset of action so bridging is

usually not needed. Strict compliance with new agents is critical Role of Antiplatelets Limited data on the benefit of aspirin In primary prevention of stroke in AF, may reduce risk by 0.8%/yr (# needed to treat-125) For secondary prevention in those with TIA or strokes aspirin associated with risk reduction of 2.5%/year (# needed to treat-40) These data based on meta analysis. In the study that showed the

most benefit, 325mg dose was used Aspirin ineffective in preventing strokes in those >75 and did not prevent severe strokes Clopidogrel + aspirin Better than aspirin alone, but benefits are tempered by a significant increase in major bleeding events Studies show clear benefit of warfarin over C+A and Eliquis over C+A HAS-BLED score for bleeding risk on oral anticoagulation in atrial

fibrillation Feature HTN (Systolic 160mmHg) Abnormal renal function Abnormal liver function Stroke in past Bleeding Elderly Labile INRs

Score if present 1 1 1 1 1 1 1 Drugs

1 NSAIDS, antiplatelets ETOH 1 NON-PHARMACOLOGIC STROKE PREVENTION Left Atrial Appendage (LAA) Occlusion By:

WATCHMAN Device (Boston Scientific) Amplatzer cardiac plug (St. Jude) LAA Occlusion by using LARIAT (SentreHEART) device that ties off the LAA epicardial snare Requires subxiphoid pericardial approach Surgical excision of the LAA for pts undergoing cardiac surgery Yields inconsistent results Masoudi FA, Calkins H, Kavinsky C; 2015 ACC/HRS/SCAI Left atrial Appendage Occlusion Device Societal Overview, JACC 2015;Jun 29

RATE CONTROL Resting rate < or = to 80, or average awake rate <100 Exercise rate should not exceed >100% of maximum predicted exercise rate Rationale for Rate Control This is an important strategy as it Impacts QOL Reduces morbidity Decreases potential for developing tachycardia induced

cardiomyopathy When selecting which agent(s) to use, must consider symptoms, hemodynamic status, presence of HF Beta blockers, non-dihydropyridine CCBs, digoxin, amiodarone, sotalol are the main considerations When rapid control of ventricular rate during AF required, IV meds or electrical CV may be used.

May increase TE risk in those inadequately anticoagulated AV Node Ablation as Rate Control Strategy Permanent Pacemaker implantation with subsequent AV node ablation effectively controls and regularizes ventricular heart rate and in select patients, improves symptoms Those most likely to benefit are those with symptomatic AF with RVR that is either non responsive to medications or the pt is intolerant to the meds

Usually reserved for the elderly, as it makes one pacemaker dependent Rate control meds no longer needed, but still require anticoagulation RHYTHM CONTROL Rationale for Rhythm Control This is a chance for shared decision making with the pt. Always treat precipitating or reversible causes first

All rhythm control options should be considered only under optimal TE prevention strategies. If symptoms not controlled with rate regulation, or pt less than 65 yrs old, it is reasonable to pursue restoration of NSR Choices include Pharmacologic, Ablation, Electrical Cardioversion alone or in combination Drugs that can convert: Amiodarone (IV/PO), Dofetilide (PO), Flecainide (PO), Propafenone (PO), Ibutilide (IV)

Drug Selection for Rhythm Control AF Ablation Invasive procedure to isolate the atrial impulses causing AF and ablating those electrical pathways. Most common way is using radio frequency ablation, but cryo-ablation is now also being used. Associated with higher risk than antiarrhythmic drugs, but is generally more effective over the long term. Usually recommended for pts with symptomatic

paroxysmal or persistent AF who are refractory or intolerant to at least 1 antiarrhythmic drug Electrical Cardioversion Recommended for symptomatic AF with RVR that does not respond promptly to pharmacologic therapies and contributes to ongoing ischemia, hypotension or CHF Ideally, should be anticoagulated for 3 weeks prior, placed on an antiarrhythmic med, with a TEE to rule out intraatrial clot, cardioversion then performed immediately following TEE. If clot is seen, CV is not performed.

If AF is clearly less than 48 hours in duration, CV can be performed without TEE. Pt. should be anticoagulated ASAP. TE is most likely to occur within 72 hours after CV, can be as long as 10 days. References Cairns JA, Connolly S, McMurtry S, Stephenson M, Talajic M; CCS

Atrial Fibrillation Guidelines Committee. Canadian cardiovascular society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol. 2011 Jan-Feb;27(1):74-90. Prystowsky EN, Padanilam BJ, Fogel, RI. Treatment of Atrial Fibrillation. JAMA. 2015;314(3):278-288. Moss JD, Cifu, AS. Management of Anticoagulation in Patients with

Atrial Fibrillation. JAMA. 2015;314(3):291-292. Chugh, A, Masoudi FA, Calkins H, Davisnsky, C. 2015 ACC/HRS/SCAI Left Atrial Appendage Occlusion Device Societal Overview. JACC. 2015: June 29. January, CT, Wann, LS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC. Vol 64, No 21. e1-79.

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