Atrial Fibrillation- Management

Atrial Fibrillation – Management

Brian Olshansky, MD

Atrial Fibrillation – Management

The Challenge and New Solutions

(Part 1 of 2)

Brian Olshansky, MD

Professor Emeritus of Medicine

University of Iowa Hospitals

72 yo female with palpitations

•CC: debilitating fatigue, dyspnea 2-3 times/day

•PMH: hypertension, diabetes

•Meds: metoprolol 25 mg bid

•Px: BP: 144/94, P: 120, irregular

–Lungs: clear

–Heart: normal S1 and S2

Electrocardiogram

Atrial Fibrillation – Management

Brian Olshansky, MD

Echocardiogram

•Normal left ventricular function

•No valvular abnormalities

•LV wall thickness = 1.3 cm

•LA size = 4.2 cm

Event monitor

•Episodes of sinus rhythm

•Episodes of asymptomatic atrial fibrillation

•Episodes of rapid rates in atrial fibrillation during symptoms

Atrial fibrillation - classification

Permanent

Fuster V. Circulation 2006; 114:e257-e354

Atrial Fibrillation – Management

Brian Olshansky, MD

Patient with AF not anticoagulated

Complaint - dizziness

CHADS2 risk stratification

CHA2DS2-VASc now recommended

Rietbrock S. Am Heart J 2008; 156:57-64

Chugh SS. J Am Coll Cardiol 2001; 37:371-78

Rockson SG. J Am Coll Cardiol 2004; 43:929-935

CHA2S2-VASc risk stratification

Atrial Fibrillation – Management

Brian Olshansky, MD

ASSERT trial

Subclinical atrial tachycardias and stroke

•Atrial tachycardia > 6 minutes, rate >190 bpm → greater risk for stroke

•2580 patients with pacemaker or ICDs

•Patients in the ASSERT trial with CHADS2 score of 1 with 1 event/year of AT/AF have 0.56 %/year – not enough for aggressive anticoagulation

Healy J. New Engl J Med 2012; 366:120-129

Warfarin

•The gold standard

•No one’s favorite drug

•Requires time in therapeutic range

•Gender differences exist

Warfarin anticoagulation in AF

Hart RG. Ann Intern Med 1999; 131:492-501

Atrial Fibrillation – Management

Brian Olshansky, MD

Warfarin – therapeutic range

•INR 2.0 - 3.0 = therapeutic range

•INR > 2 = risk of bleeding ↑, no reduction in risk for stroke

•INR < 2 = risk of stroke ↑↑

Hylek EM. N Engl J Med 1996; 335:540–546

Time in therapeutic range (TTR)

TTR<65% TTR≥65%

C+A = clopidogrel and aspirin

OAC = oral anticoagulation

Connolly S. Circulation. 2008; 118:2029-2037

AFFIRM - gender differences

Sullivan RM. Am Heart J 2012 in press

Atrial Fibrillation – Management

Brian Olshansky, MD

HAS-BLED bleeding risk score

Traditional anticoagulation

Warfarin is no one’s favorite drug

Is there a better way?

Is home monitoring the answer?

First event with home monitoring the same as clinic testing

Matchar DB. N Engl J Med 2010; 363:1608-20

Atrial Fibrillation – Management

Brian Olshansky, MD

Other anticoagulants

•Aspirin

•Clopidogrel (and in combination)

•Direct thrombin inhibitors (dabigatran)

•Direct factor Xa inhibitors

(rivaroxaban, apixaban, betrixaban, edoxaban)

ACTIVE trial

Clopidogrel plus aspirin combination was slightly better than aspirin alone

Connolly S. N Engl J Med 2009; 360:2066-78

Anticoagulation for AF and bleeding

Hansen ML. Arch Intern Med 2010; 170:1433-1441

Atrial Fibrillation – Management

Brian Olshansky, MD

RE-LY: dabigatran

Connolly SJ. N Engl J Med 2009; 361:1139-1151

Mean CHADS2 – 2.1; TTR 64%

•Dabigatran 150 mg twice a day was associated with a lower risk for stroke and thromboembolism, compared to warfarin or 110 mg bid dose

•Dabigatran does not require measurements of an INR, it may be superior to warfarin

•Hard to determine the level of anticoagulation

•Risk of bleeding

•Expanse

ROCKET AF: rivaroxaban

Patel MR. N Engl J Med 2011; 365:883-891

•Rivaroxaban: 20 mg daily

•TTR 55%

•CHADS2 – 3.5

•There was no significant difference in the event rate over time (warfarin vs. rivaroxaban)

AVERROES: apixaban

Apixaban was superior to aspirin in terms of number of strokes or systemic embolic events in the long term follow up

Connolly S. N Engl J Med 2011; 364:806-17

Atrial Fibrillation – Management

Brian Olshansky, MD

ARISTOTLE: apixaban

Granger CB. N Engl J Med 2011; 365:981-992

•Apixaban was superior in terms of the rate

of thromboembolic events, major bleeding events

•CHADS2 – 2.1

•Apixaban 5 mg bid

•TTR 62%

ACC/AHA guidelines

Fuster V. Circulation 2006; 114:e257-e354

Anticoagulation – the bottom line

•Warfarin – gold standard, “high risk” patients

–Despite the fact that clinical trials show benefits of novel anticoagulants:

1.Long term experience

2.We can measure the level of anticoagulation

3.Less expensive

4.Renal/valvular heart disease issues

•“Risk” is still being refined

•Dabigatran or another drug may replace warfarin soon (even in lower risk patients)