Updated guidelines for the treatment of AF 2010.

Said KhaledProfessor of CardiologyAin Shams University

2010

Updated guidelines for the treatment of AF 2010.

الرحمن الله بسمالرحيم

First diagnosed episode of atrial fibrillation

Paroxysmal(usually <48 h)

Persistent(>7 days or requires CV)

Long-standingPersistent (>1 year)

Permanent ( Accepted )

Camm et al., AF Guidelines 2010 Eur heart J 2010

AF TREATMENT GOALS• Treatment goals in symptomatic pts

– frequency of recurrences– duration of recurrences– severity of recurrences

• Minimize risk of tachycardia induced cardiomyopathy

• Safety is primary concern

Maintenance of SR

Pharmacologic

Stroke prevention

Nonpharmacologic

Class IA Class ICClass III-blocker

Catheter ablationSurgery (MAZE)Pacing

Pharmacologic• Warfarin• Thrombin inhibitor• Heparin• Aspirin

Nonpharmacologic• Removal / isolation

LA appendage

Rate control

Pharmacologic• Ca2+ blockers• -blockers• Digitalis• Amiodarone

Nonpharmacologic• Ablate and pace

Prevent remodeling ACE-IARB

AF: TREATMENT OPTIONS

Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.


His Bundle Ablation

TransvenousCatheter Ablation

PermanentVentricular Pacing

AV Node Ablation forAtrial Fibrillation

Pro’s Con’s Simple Pacemaker dependence High success Permanent Improved QOL Anticoagulation regular rate controlled rate

Indications If rate cannot be controlled with pharmacologic agents or tachycardia-mediated

cardiomyopathy is suspected, Class IIb, Level of evidence C

Circulation 2006;114:700-752

If pharmacologic therapy is insufficient or associated with side effects.” Class IIa, Level of evidence C

Maintenance of SR

Pharmacologic

Stroke prevention

Nonpharmacologic





LA appendage

Rate control






Maintenance of SR

Pharmacologic

Stroke prevention

Nonpharmacologic





LA appendage

Rate control






Class IA

Quinidine

Procainamide

Disopyramide

Class IC

Propafenone

Propafenone SR

Flecainide

Class III

Sotalol

Amiodarone

DofetilideDronedarone

Miller and Zipes. In: Braunwald, et al (eds). Heart Disease. 6th ed. 2001.

Rhythm Control for AF: Commonly Used Oral Antiarrhythmic Drugs

AF Efficacy: Maintaining NSR > 6 Months

0

10

20

30

40

50

60

70

NSR

, %

Nodrug

Quin Diso Prop Flec Sot Dof Azim Amio


1. Honloser et al. Lancet 356:1789-94, 2000 2. Van Gelder et al. N Engl J Med 347:1834-00, 20023. Carlsson et al. J Am Coll Cardiol 41:1690-6, 2003 4. AFFIRM Investigators N Engl J Med 347:1825-33, 2002

Combined Results ofPIAF, RACE, STAF, and AFFIRM

STUDY N FU (YR) PRIMARY RHYTHM

SINUS EMBOLI HOSPADMIT DEATH

PIAF1 252 1.0 no difference 56% NA

24% / 69%p = 0.001

1.6% / 1.6%

p = ns

RACE2 522 2.3 no difference 39%

5.5% / 7.9%

p = nsNA

7.0% / 6.8%

p = ns

STAF3 200 1.6 no difference 38%

2.0% / 5.0%

p = ns

26% / 54%p < 0.001

8.0% / 4.0%

p = ns

AFFIRM4 4060 3.5 no difference 62%

3.8% / 3.9%

p = ns

60% / 68%p < 0.001

15% / 18%p = 0.08

TOTAL 5034 3.2 no difference 58%

4.4% / 4.9%

p = ns

57% / 67%p < 0.001

13% / 15%p = 0.11

Comparing Rate Control versus Rhythm Control

Rate Control or Rhythm Control?

• Four trials (PIAF 2, AFFIRM, RACE and STAF) have shown that rate control is not inferior to rhythm control.

A trend toward an even better outcome for rate control therapy is consistent in all studies. Rate control = Rhythm control

Maintenance of SR

Pharmacologic

Stroke prevention

Nonpharmacologic


PacingCatheter ablationSurgery (MAZE)



LA appendage

Rate control






N Engl J Med 2002;346(26):2066

Devices for AF: Living Better Electrically

Focal Origin of Atrial Fibrillation

Hassaiguerre M, NEJM, 1998

• 94% of AF triggers from Pulmonary Veins

• “90 – 95% of all AF is initiated by PV ectopy”

RA LA

CS

FO

SVC

IVC

Pulmonary Veins

17 31

6 11

PV-d

HRA

CS-p

CS-5/6CS-3/4

PV-1/2

PV-3/4

PV-5/6PV-4/5

PV-2/3

PV-6/7PV-7/8PV-8/9

PV-9/10PV-10/1

CS-d

CS-7/8

I

100 ms PVA A

Before Ablation During Ablation

After Ablation

A PV

Lasso™ Guided PV Isolation

Atrial Fibrillation: Catheter ablation of PV focus

The fluoroscopy images show the ablation catheter (ABL) in the left anterior oblique (LAO) and right anterior oblique (RAO) projections.

Nathan, Circ Res, 1969?

Left Atrium, Posterior WallPulmonary Vein Isolation

Atrial Flutter: Catheter mapping

Note sequential activation along the leads of the blue mapping catheter. The yellow ablation catheter is placed in the isthmus between the tricuspid valve and the eustachian valve of the IVC.

Atrial Flutter: Catheter ablation

Ablation in the tricuspid isthmus creates a line of block that interrupts the flutter circuit. Subsequent pacing from the coronary sinus demonstrates bi-directional block along the line of ablation.

Catheter ablation vs AAD




Rate control plusanticoagulation preferred

Rhythm controlpreferred

• No or lesser AF symptoms• Longer AF Hx• More SHD• Toxicity Risk• Elderly• Greater risk of

proarrhythmia

• Greater AF symptoms• Symptoms despite rate

control• Younger age• No or lesser SHD• Rx option of class IC AAD

In anticoagulation candidates, continue anticoagulation indefinitely

APPROACHES TO AF THERAPY

Maintenance of SR

Pharmacologic

Stroke prevention

Nonpharmacologic





LA appendage

Rate control








3000838-18

• WATCHMAN LAA Closure Device

• In PROTECT AF, all cause stroke and all cause mortality risk are non-inferior to warfarin

Whats new in AF ttt 2010Transcathete LAA isolation:

Amplatzer Cardiac (LAA) Plug Design

AF in 2010Conclusions

No marked progress in the pharmaceutical cure of AF.

Dronedarone seems to be effective in AF patients with mild or no HF.

Ablation techniques are not yet recognized as a first line treatment.

If we initiate rhythm control therapy early, Could this result in sloweing progression of AF OR

prevent complications ??????

Thank you

Updated guidelines for the treatment of AF 2010.

Documents

treatment of af

permanent af

af guidelines

diagnosed af

af episode

paroxysmal af

af paroxysms

sr maintenance