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Atrial Fibrillation in the Era of the Accountable Care OrganizationJohn Windle MDOctober 18, 2013Professor and Chief of CardiologyUniversity of Nebraska Medical Center

Ha ha ha, Biff. Guess what? After we go to the drugstore and the post office, Im going to the vets to get tutored.Conflict of InterestI have no relevant conflicts. Just lots of opinionsAtrial Fibrillation in the Era of the Accountable Care Organization A Quick Review of the BasicsThe importance of DefinitionsThe importance of atrial transportThe clinical trials that drive the guidelinesFilling in the GapsRate Control versus Rhythm Control issuesPerspectives on bleeding versus stroke but not discussing new therapies.Musings on how this might work in an ACO modelAtrial FibrillationMost common sustained symptomatic tachyarrhythmia. Over 3,000,000 Americans suffer from atrial fibrillation.Incidence with age and presence of structural heart diseaseSlightly more common in men than women15%(75,000 per year) of all strokes occur in AF patientsOne of the top causes of hospitalizations and extension of stays in Hospitals

Bialy et al. Journal of the American College of Cardiology 1992; 19(3):41A.Prystowsky et al. Circulation. 1996; 93(6):1262-1277.Wolf et al. Archives of Internal Medicine. 1987; 147(9):1561-1564.14-12-10-8-6-4-2-0-MenWomenMenWomenChronic AFParoxysmal AF14-12-10-8-6-4-2-0-2-yr Incidence (per 1000)2-yr Incidence (per 1000)12.96.75.42.20.90.54.81.50.7030-3940-4950-5970-7960-69----30-3940-4950-5970-7960-69----Kannel et al. American Heart Journal. 1983;106(2):389-396.AgeAge12.74.80.60.5000.40.51.99.2Incidence of Atrial Fibrillation (Framingham Study)Consequences of Atrial FibrillationArrhythmia-associated symptoms, look at exertional symptoms of shortness of breath, exertional dyspnea and decreased exercise tolerance. LV function: Impact of atrial transport and diastolic function.Tachycardia-mediated cardiomyopathy (heart rates over 130 b/m)2-fold in cardiac mortality5-fold in risk of stroke Why do I feel like crap?Myocardial and Hemodynamic Consequences of Atrial fibrillationLoss of atrial contraction decreases cardiac output9% drop in C.O. in canine model15% drop in C.O. in irregular response vs. same average rate pacing.Decrease in coronary blood flow with irregular ventricular rhythm.Tachycardia-induced cardiomyopathy (heart rate >130 for several weeks).LVH (diastolic dysfunction) accentuates the importance atrial contraction.

The impact of atrial contribution by cardiac doppler

Atrial Fibrillation-The 3 PsParoxysmal-Self-limited, often occurring in structurally normal heartsPersistent-Requiring intervention, either chemical (antiarrhythmic drugs) or electrical to restore sinus rhythmLong-standing persist-a term created by cardiac electrophysiologists to not give up.Permanent-UncardiovertableAtrial Fibrillation Guidelines

Paroxysmal Atrial FibrillationVasovagal-nocturnal, triggered by stress, meals or alcoholSelf-limited but shortened duration with propafenone or flecainideOften have pulmonary vein fociAmenable to Ablative therapyPersistent Atrial FibrillationNeed an intervention to restore sinus rhythmMore likely to involve structural heart disease: Cardiac effects of hypertension and LVH, prior myocardial damage such as MITry to figure out the symptom trigger: Rate, regularity or Atrial synchrony and atrial transport.Permanent Atrial FibrillationUn-cardiovertable atrial fibrillationDurationLeft atrial sizeComorbiditiesAbsence of SymptomsConversion to NSRMaintenance of NSRVentricular Rate ControlPrevention of ThromboembolismDecision Points for Atrial FibrillationNSR = normal sinus rhythmShort TermLong TermTimeRate Control TherapyA-V Nodal Agents (slow ventricular response)Digoxin-increases vagal tone, reduces resting heart rate but not exercise rateBeta Blockers-underutilized but most effectiveCalcium Channel AgentsDiltiazem and verapamil not nifedipineAdenosineA-V Node Ablation with pacemaker placementSingle versus Bi-V deviceRhythm Control TherapyAtrial Muscle Agents (restoration and maintenance of sinus rhythm)Procainamide and Quinidine-What we learned about in School but of limited use and availability nowPropafenone, Flecainide-Good for acute conversion and normal hearts (Pill-in-the Pocket)Disopyramide-Still in good option for some, decreases vagal toneSotalol and Dofetilide-Torsades de Pointes but otherwise great agentsDronederone-very limited use.Amiodarone*

*The Vaughn-Williams Classification system is easy but wrong.The Affirmed TrialThe Affirmed Trial-Rate Control versus Rhythm Control in Patients with Atrial FibrillationCritical Study: Randomized Control TrialRhythm Control no better than Rate ControlRate control less costlyThe Affirmed Trial: Part IIShort follow-up on elderly, asymptomatic patientsBased on an intention to treatFailure based on first recurrence versus time spent in desired rhythmVery high overlap in assigned patients in their actual rhythm (sinus rhythm versus atrial fibrillation).Not a comparison of atrial fibrillation versus sinus rhythm (The sinus rhythm patients did significantly better)

Atrial Fibrillation; now what?!

No significant improvement in quality of life with rhythm control strategy in multiple trials above. STAF and HOT CAF showed increase in exercise tolerance.Its just AF; it wont KILL ME.

HF promotes AF, AF exacerbates HF, and patients with either who develop the other, share a poor prognosis.Stroke in AF averages 5% per year!1.5% annual in 50-59y to 23% annual in 80-89 yrs.Framingham Heart Study (1983);The Regional Heart Study Whitehall StudyManitoba Study (1995)

Framingham Data.Excess mortality in AF patients compared to matched (non-AF).My Take Home Messages:Yep-Sinus rhythm and rate controlled atrial fibrillation equivalent in asymptomatic, elderly patients followed over 3-5 years.Yep-Lower utilization of resources with rate control strategyBut, Didnt answer sinus versus rate controlMost of my patients are not truly asymptomaticAtrial fibrillation causes a 5-10% drop in EF in most patients, what do you think will happen over time? AnticoagulationAnticoagulation is recommended for ALL patients with atrial fibrillation, except those with LONE AF or contraindications.Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factorAspirin 81-325 mg for low-risk patients, or those with CI to oral anticoagulationAnticoagulation for atrial flutter is recommended as per AF.Long term anticoagulation with vitamin K antagonist is NOT recommended for primary strike prevention in patients