Cards 2000

1
Managing Atrial Fibrillation Today
A John Camm, MD Professor of Clinical
Cardiology St. George's University of
London London, UK
2
Publication Trends
Atrial Fibrillation
Publication trends according to PubMed, accessed
February 2008.
3
Atrial Fibrillation Two Diseases
Cardiovascular Continuum
Cardiovascular remodelling
Atrial remodelling
?
AF
Hypertension Obesity Metabolic syndrome
Autonomic Imbalance
Permanent
Paroxysmal
Persistent
4
AF Increases Risk Along the Cardiovascular
Continuum
Remodelling
Ventricular dilation
MI
Heart failure
Atherosclerosisand LVH
End-stage microvascular andheart disease
Atrial fibrillation1,2
Risk factors (diabetes, hypertension)
Death

• Benjamin EJ, et al. JAMA. 1994271840-844
• Krahn AD, et al. Am J Med. 199598476-484
• Nakashima H, et al. Circulation.
  20001012612-2617
• Tsai CT, et al. Circulation. 20041091640-1646.

5
Lone AF - Olmsted County

• 76 patients lone atrial fibrillation
• Mean age 44.2 11.7 years
• Male 78

Jahangir A, et al. Circulation.
20071153050-3056.
6
AFFIRM and RACE Main Results
RACE Death, CVA/TIA, hospitalization -5.4 90
CI(-11, 0.4)
AFFIRM All-cause death 27 vs 26 (P 0.058 )
100
17.2
Rate control
30
90
25
80
20
22.6
Rhythm control
70
Event-free survival ()
Rhythm control
15
Mortality ( patients)
60
10
Rate control
50
5
0
0
0
1
2
3
4
5
6
0.0
0.5
1.0
1.5
2.0
2.5
3.0
2.5
Years
Years
7
AF- CHF 10 Endpoint CV Death
AF 1 6 hrs or 1 10 min plus DC shock within
6m
CHF LVEF ? 35 and NYHA II-IV
100
1376 Randomized
Logrank P 0.594
80
Rhythm control
Rate control
60
694
682
Survival probability
Hazard ratio 1.058 (95 CI, 0.86 to 1.30)
39 5.6
28 4.1
40
Lost to F/up Heart transplant   Completed trial
or died
7 1.0
5 0.7
20
Rhythm control Rate control
647 94.9
650 93.7
0
0
12
24
36
60
48
Time to CV death (months)
Mean F/up 37 19 months (max 72 months)
8
Atrial Fibrillation/History of Atrial Fibrillation
Antithrombotic therapy according to guidelines
Clinical evaluation, ECG, echocardiogram, thyroid
function tests, etc
Permanent AF
Persistent AF
Paroxysmal AF
Asymptomatic
Suitable for DCC
Rhythm control
Rate control
Remains symptomatic
Failure of rhythm control
9
AFFIRM Study
Influence of Rate Control
Survival ( patients)

• Prognosis, quality of life (QoL), and functional
  status
• Pts grouped by quartileof achieved HR at rest
  and achieved exercise HR (6-minute walk)
• Complete data
• 680 pts - HR (rest)
• 349 pts - HR (exercise)
• 118 pts - QoL

100
80
60
HR 1.03 (0.88-1.33) P 0.70
40
Not achieved ( 80 bpm, 37) Achieved (? 80 bpm,
63)
20
0
0 1 2 3 4 5 6
Years
Cooper HA, et al. Am J Cardiol. 2004931247-1253.
10
What is Adequate Rate Control?
Concerns

• Definition of heart rate control based on
  benefits from short term hemodynamic studies
• Not well studied with regards to regularity vs
  irregularity
• No standardised method of assessment

• Proposal
• 60 80 bpm at rest
• 90 to 115 bpm during moderate exercise

ACC/AHA/ESC Guidelines. Eur Heart J.
2006272099-2140.
11
Recent (2006) AF Guidelines

• Class III
• Digitalis should not be used as the sole agent to
  control the rate of ventricular response in
  patients with paroxysmal AF. (LoE B)
• Class IIa
• Digoxin is effective to control the heart rate
  at rest and is indicated for sedentary
  individuals and in patients with HF or LV
  dysfunction. (LoE B)

12
MILOS
Multicentre Longitudinal Observational Study

• 1285 CRT patients
• 243 (19) with AF
• 118 had AVN ablation

• 125 received AADs
• Follow-up 34 months

AF CRT had same ACM as SR CRT AF CRT AVNA
had better ACM and HFM survival than AF CRT
Gasparini M, et al. Eur Heart J.
2008291644-1652.
13
PABA - CHF LVEF

• Multicenter randomized, unblinded trial
• EF 40, refractory AF
• 11 randomization PVI vs AVN ablation with BiV
  ICD

P 0.003
P
P 0.002
P 0.02
Month
Khan MN, et al. Circulation. 2005112II-394.
Abstract 1929.
14
Antithrombotic Treatment in AF The Euro Heart
Survey

• 182 hospitals, 35 countries
• n 5333
• 2706 (52) no intervention planned

Camm A, et al. Eur Heart J. 20052624222434.
15
CHADS(2) Score

• Combination of AFI and SPAF schemes
• 1 Congestive Heart Failure
• 1 Hypertension
• 1 Age 75 years
• 1 Diabetes Mellitus
• 2 Prior Stroke or TIA

Low
Moderate
High
Gage BF, et al. JAMA. 20012852864-2870.
16
Anticoagulation in Atrial Fibrillation
ACC/AHA/ESC Guidelines. Eur Heart J.
2006272099-2140.
17
AADs for Prevention of AF after DCC
Systematic Review of RCTs
Class IA Class IC Metoprolol Class
III Amio Dofetilide Sotalol Q vs Class I Q
vs Sotalol Amio vs Class I Amio vs
Sotalol Sotalol vs Class I
Lafuente-Lafuente C, et al. Arch Intern Med.
2006166719-728.
18
ACC/AHA/ESC AF Guidelines Revised 06
Maintenance of sinus rhythm
Heart Failure
No heart disease
Hypertension
CAD
LVH
Flecainide Propafenone Sotalol
Dofetilide Sotalol
Amiodarone Dofetilide
Yes
No
Flecainide Propafenone Sotalol
Amiodarone
Amiodarone Dofetilide
Amiodarone
Amiodarone Dofetilide
19
Pill in the Pocket CCV
Alboni P, et al. N Engl J Med. 20043512384-2391.

20
Pill-in-the-Pocket Technique

• Patients with
• No LV dysfunction, valvular, or IHD
• Infrequent symptomatic episodes of paroxysmal AF
• systolic BP 100 mm Hg and resting heart rate
  70 bpm
• Understanding of how and when to take the
  medication

Patients with paroxysmal AF
Appropriate thrombo- prophylaxis
Is Pill in Pocket therapy appropriate?
Yes
No
Pill in Pocket flecainide or propafenone
Standard beta blocker
21
AF Ablation or Antiarrhythmic Drugs?
APAF
100
87
80
p 0.001
60
Freedom from AF recurrence
40
29
20
0
PVI
AAD
2o EP Reduction in LA size in the PVI group