Question

1. Question • 67yo male CEO of manufacturing company presents to your office for routine annual physical exam. He has past history of well controlled DM, and HTN. He is well dressed (wearing a suit and tie). Denies any symptoms of palpitations, SOB, chest pain, or exertional dyspnea. He is on lunch break and in a hurry to return for a meeting. On PE, tachycardia, irregularly irregular rhythm is noted. Routine vitals reveal HR 155. EKG reveals R=155, atrial fibrillation. Which of the following is the next step in therapy?

2. Answers • A. start metoprolol, and cardiology referral • B. Send to ER • C. Start chronic anticoagulation, and metoprolol and follow up in 3 months • D. Cardiology referral

3. Question • 75yo female with pmhx of PAF, DM, HTN, CVA, and history of gastric AV malformations, and recurrent gi bleeding presents to your office. She denies any symptoms of heart palpitations, CP, or SOB. She is on baby asa once daily for cva prophyllaxis due to recurrent anemia on coumadin. Which of the following is the next step in therapy.

4. Answers • 1. Rechallenge anticoagulation with lower dose eliquis • 2. Re-challenge coumadin therapy, keep INR 1.5-2.0 • 3. Referral for procedural therapy for cva prophyllaxis • 4. change asa to plavix

5. Advances in Atrial FibrillationWatchman Device Vijai Tivakaran, DO, FACC, FACOI, FASE, FASNC, FSCCT, RPVI

6. No disclosures.

7. Format • Summary of Atrial fibrillation, Big Picture • Rate Control vs Rhythm Control • Afib ablation procedure • CVA prophylaxis/anticoagulation • Watchman Device • Interruption or Discontinuation of Oral Anticoagulation for Surgery/Procedures

8. Background • Afib is the most common cardiac rhythm disturbance • Affects over 3 million Americans, and expected to double in next 25 years • Expensive- costs $16 billion annually • Affects 6% over the age of 65 • >467,000 cases of afib yearly as primary diagnosis of hospitalization • Patients with afib, in general, are hospitalized 2X as much as patient without afib

9. Background • Lifetime risk of afib is 26% for men, and 23% for women • Afib is often associated with structural heart disease and other co-occuring chronic conditions • There is a 5 fold increase risk of stroke when you have atrial fibrillation

11. Definitions • AF is a supraventricular tachyarrhythmia with uncoordinated atrial activation, and ineffective atrial contraction

14. AV Node • Ventricular rate is determined by the conduction and refractory properties of the AV node

16. Question • 67yo male CEO of manufacturing company presents to your office for routine annual physical exam. He has past history of well controlled DM, and HTN. He is well dressed (wearing a suit and tie). Denies any symptoms of palpitations, SOB, chest pain, or exertional dyspnea. He is on lunch break and in a hurry to return for a meeting. Tachycardia, irregularly irregular rhythm is noted on PE. Routine vitals reveal HR 165. EKG reveals R=165, atrial fibrillation. Which of the following is the next step in therapy?

17. Answers • A. start metoprolol, and cardiology referral • B. Send to ER • C. Start chronic anticoagulation, and metoprolol and follow up in 3 months • D. Cardiology referral

18. Symptoms • Symptoms range from nonexistant to severe • Possible symptoms include fatigue, palpitations, dyspnea, hypotension, syncope, or CHF • Most common symptom of afib is fatigue

19. Consequences • Asymptomatic patients can develop tachycardia induced ventricular dysfunction • Tachycardia induced cardiomyopathy • Occurs when the heart rate is not appropriately controlled

21. Rate Control VS Rhythm Control • Theoretical Benefits of Rhythm Control • 1. Improved hemodynamics • 2. Relief of Symptoms • 3. Improved exercise tolerance • 4. Reduced risk of stroke • 5. Avoidance of anticoagulants

23. AFFIRM Trial • No difference in rate control vs rhythm control in death, disabling stroke, major bleeding, or cardiac arrest, NSR maintained in only 63% of patients in the rhythm control group

24. Our Approach-Evidence + Experience • Rhythm control as preferred therapy • First episode of afib • Reversible cause (acute illness, COPD exac, s/p surg) • Symptomatic patient despite rate control • CHF precipitated by the afib • Young afib patient, (to avoid chronic electrical and anatomic remodeling that occurs with afib) • Tachycardia induced cardiomyopathy

25. Our Approach-Evidence + Experience • Rate control as preferred therapy • Age>65, asymptomatic • Recurrent afib • Previous antiarrhythmic drug failure • Unlikely to maintain SR, (enlarged LA on Echo)

26. Approach to Selecting Drug Therapy for Ventricular Rate Control*

27. Rhythm Control • Outpatient initiation • Amiodarone • Dronedarone • Inpatient initiation • Sotalol • Dofetilide

28. Triggers of AF • Ectopic focal discharges often initiate AF. Rapidly firing foci initiating paroxysmal AF arise most commonly from the pulmonary veins • These observations led to the development of pulmonary vein isolation as the cornerstone for radiofrequency catheter ablation

29. Catheter Ablation

37. Remodeling of left atrium • AF progresses from paroxysmal to persistent in many patients and subsequently results in electrical and structural remodeling that becomes irreversible with time • For this reason, accepting afib as permanent in a patient may render future rhythm-control therapies less effective • Younger people may want to be candidates for future rhythm control therapies • Early intervention with a rhythm control strategy to prevent progression of AF may be beneficial

38. Risk of Stroke • Increased risk of stroke and/or thromboembolism owing to the formation of atrial thrombi, usually in the left atrial appendage

46. AF Creates Environment for Thrombus Formation in Left Atrium AF-Related Stroke and the Left Atrial Appendage • Stasis-related LA thrombus is a predictor of TIA1 and ischemic stroke2. • In non-valvular AF, >90% of stroke-causing clots that come from the left atrium are formed in the LAA3. 1. Stoddard et al. Am Heart J. (2003) 2. Goldman et al. J Am Soc Echocardiogr (1999) 3 Blackshear JL. Odell JA., Annals of Thoracic Surg (1996)

47. Parekh A et al. Circulation. 2006 Sep 26;114(13):e513-4

49. Antithrombotic Drugs in Routine Use for Nonvalvular Afib Anticoagulants Antiplatelet • Heparin • LMWH • Warfarin • Direct Thrombin Inhibitors • Factor Xa inhibitors • Asa • clopidogrel