Cardiovascular Update 2014 Workshop

Atrial Fibrillation – Stroke, Bleeding and why is it so confusing ?

Dr Ken Butcher Dr Micha Dorsch

Högertrafikomläggningen

Patient 1: VA• 84 year old lady

• Long history of hypertension currently well controlled on Perindopril, Bisoprolol, Chlorthalidone and Amlodipine

• Type 2 diabetes on Metformin (HBA1c: 7.4)

• Dyslipidaemia on Rosuvastatin (LDL 1.6)

• Routine office visit with family physician: no symptoms, but pulse irregularily irregular

What next ?

VA: EKG

What other tests?

Other tests

• Thyroid function test• Haemoglobin• ? Echo• ?? Ischemia work up• ??? Other tests really required

Anticoagulation?

Anticoagulation ?• CHADS2 = 3, equivalent to annual stroke

risk of 5.9%

• CHA2DS2-VASC = 5, equivalent to annual stroke risk of 15.3% (2012 ESC guideline update)

• HAS-BLED = 2, equivalent to 1.88 major bleeds in 100 patient years

All calculations performed on: www.mdcalc.comMajor bleed: bleeding requiring transfusion or hospitalisation or Hb drop greater 2g/L

Figure 1

Canadian Journal of Cardiology 2014 30, 1114-1130DOI: (10.1016/j.cjca.2014.08.001) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

2014-11-30

Rate or rhythm control ?

Rate vs Rhythm control: AFFIRM

AFFIRM investigators: A comparison of rate control and rhythm control in patients with Atrial fibrillation. NEJM 2002; 347: 1825-33

What is rate control ?

Van Gelder et al. Lenient vs. strict rate control in patients with atrial fibrillation. NEJM 2010;362: 1363-73

Rate control: Strict vs lenient

Not so confusing at all, is it?• Started on Coumadin, opted for rate

control

• No further cardiac testing

• 12 months follow-up– Pt remains asymptomatic– Changed from coumadin to rivaroxaban by

family physician (difficult to control INR)

Patient 2: JA• 56 year old lady• Paroxysmal atrial fibrillation since 2001• Very symptomatic with one episode every 3-6

months• 18 admissions requiring DCCV, 5 Cardiologists• Intolerant of Sotalol, Dronedarone, Atenolol,

Warfarin, Rivaroxaban and Dabigatran• On Diltiazem 90 mg bid and ASA (sometimes)• 19. admission RAH ER Jan 2014

Admission 19, Cardiologist Nr 6

• Woke up at 05.00 with palpitations and dizziness

• Called EMS at 07.00

• EMS: A fib, rate 160, BP: 86/45

What next ?

Acute Management

• Attempted DCCVx3 by EMS, remains in Afib

• Procainamide i.v.: worsening hypotension

• CCU admission: spontaneous cardioversion

A fib – possible longterm strategies

• Continuous antiarrhythmic drug therapy

• Pill in the pocket approach

• Invasive management: pulmonary vein isolation

Pharmacotherapy - options

• Sotalol

• Dronedarone

• Propafenone/Fleccainide

• Amiodarone

Anticoagulation ?• CHADS2 = 0, equivalent to annual stroke

risk of 1.9%

• CHA2DS2-VASC = 1, equivalent to annual stroke risk of 2% (2012 ESC guideline update)

• HAS-BLED = 0, equivalent to 1.13 major bleeds in 100 patient years

All calculations performed on: www.mdcalc.com

JA: further management

• Changed Diltiazem bid to Tiazac XC 240 mg daily

• Started on Apixaban

• Propafenone 600mg (pill in the pocket approach)

OA review: Sep 2014• D/C Apixaban after 2 weeks for side effects and

restarted ASA

• Tolerates Tiazac XC and takes it regularly

• 2 episodes of paroxysmal A fib since, terminated by Propafenone

• Offered her workup for pulmonary vein isolation: currently not interested

Pill in the pocket approach

• 268 patient with paroxysmal atrial fibrillation and structurally normal heart

• Treated in ER with Propafenone or Fleccainide as per site investigator`s preference

• 210 treated successfully and without side effects were given pill in the pocket

• 84% success rate, no serious side effects

Alboni et al.: Out-patient management of recent onset atrial fibrillation with the pill in the pocket approach. NEJM2004; 351:2384-91.

A Fib management

Anticoagulant/Antiplatelettherapies

CHADS2/CHA2DS2-VASC SCORE

HAS BLED

Patient preference

Rhythm vs Rate control

Symptoms

Probability of maintaining SR

Patient preference

Treatable aetiological factors

Structural heart disease

Sleep disordered breathing

Hyperthyroidism…

A Fib: My approach

Figure 2

Canadian Journal of Cardiology 2014 30, 1114-1130DOI: (10.1016/j.cjca.2014.08.001) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

2014-11-30

Figure 3

Canadian Journal of Cardiology 2014 30, 1114-1130DOI: (10.1016/j.cjca.2014.08.001) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions

2014-11-30

Atrial Fibrillation – Stroke, Bleeding and why is it so confusing ?