Atrial Fibrillation: Update 2007 David L. Scher, FACP, FACC, FHRS Director, Cardiac Electrophysiology Pinnacle Health System and Associated Cardiologists, PC Harrisburg, PA Clinical Associate Professor of Medicine Pennsylvania State College of Medicine October 13, 2007
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Atrial Fibrillation: Update 2007 David L. Scher, FACP, FACC, FHRS Director, Cardiac Electrophysiology Pinnacle Health System and Associated Cardiologists,
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Atrial Fibrillation: Update 2007
David L. Scher, FACP, FACC, FHRSDirector, Cardiac Electrophysiology
Pinnacle Health System and Associated Cardiologists, PCHarrisburg, PA
Clinical Associate Professor of MedicinePennsylvania State College of Medicine
October 13, 2007
Atrial fibrillation accounts for 1/3 of all
patient discharges with arrhythmia as principal diagnosis.
2% VF
Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.
34% Atrial
Fibrillation
18% Unspecified
6% PSVT
6% PVCs
4% Atrial Flutter
9% SSS
8% Conduction
Disease3% SCD
10% VT
Classification
• Paroxysmal: recurrent (>2 episodes) that terminate spontaneously within seven days.
• Persistent: AF with duration greater than seven days, or requiring CV (drugs or electrical). Also includes “longstanding persistent AF” (continuous AF lasting greater than one year).
• Permanent: AF in which decision not to restore SR by any means is made.
2006 ACC/AHA/ESC Practice Guidelines: Changes Since 2001 Guidelines
• Incorporation of major clinical trials.• Reorganized with emphasis on clinical patient
management.• Incorporation of catheter-based ablation technologies.• Drug therapy: those approved in N. America and
Europe• Emerging importance of angiotensin inhibition.• Prophylactic therapies.
JACC 2006, 48:e149-246
Rate Control vs. Rhythm Control
StudiesAFFIRM (2002)
RACE (2002)PAF (2000)
STAF (2003)HOT CAFE’ (2004)
No study demonstrated a difference in quality of life!
Rate Control vs. Rhythm Control
• However, judgment should be exercised in applying this lack of difference of QOL to individual patients!
• Definition of rate control: less than 100 bpm over at least 18 hr monitoring period, or less than 100% of maximum age-adjusted predicted exercise heart rate.
• Regardless of treatment strategy, antithrombotic therapy is to be continued in indicated patients!
Patient Selection• Symptomatic AF refractory or intolerant to at least
one Class 1 or class 3 antiarrhythmic drug.
• Only absolute contraindication: LA thrombus (TEE before ablation in pts. with persistent AF).
• Other considerations:– Success less likely in pts. with marked LA dilatation.– Higher complication rate in very elderly.– Pts.’ desire to discontinue warfarin is not an
Appropriate Follow-up and Long-Term Management: Areas of Consensus
• IV or LMW heparin bridging.
• Warfarin for at least 2 months in all patients.
• Decision re: warfarin after 2 months based on pt. risk factors NOT presence or absence of AF.
• Long-term warfarin for pts. With CHADS > 2.
Appropriate Follow-up and Long-Term Management: Areas of Consensus
• Repeat procedures: to be deferred for at least 3 months, if symptoms can be controlled with drugs.
• Definition of major complication: permanent injury, death, requiring intervention for treatment, or prolong or require hospitalization.
Appropriate Follow-up and Long-Term Management: Areas of Consensus
• Definition of success: freedom from AF/flutter/tachycardia is primary endpoint. Has varied: freedom for AF w/ and w/o sx, 90% reduction of AF burden, presence of AA drugs.
• Recurrence defined as AF/flutter/tachycardias documented lasting > 30 seconds (does not include early recurrence blanking period of 3 months).
• Early recurrence common and not failure: 35%, 40%, 45% at 15, 30, and 60 days respectively.
• Late recurrence (> 1 yr): 5-10%.
Appropriate Follow-up and Long-Term Management: Areas of Consensus
• Minimal monitoring: – office F/U 3 months post ablation and Q 6 mos. for 2
yrs.
– Event recorder monitoring for palpitations.
– 24-hour Holter monitoring at 3-6 mo. intervals for 1-2 yrs for clinical trials.
Literature Review: Non-randomized trials
• Single procedure success, %:– Paroxysmal AF: >60 (38-78)