슬라이드 1

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1 How to manage the patients with Atrial Fibrillation Young-Hoon Kim, MD, PhD, FACC Electrophysiology Laboratory Cardiovascular Center Korea University Medical College Seoul, Korea

2 1 66, 3 ( 78 ). (42 mm). 1.? 1) DC cardioversion for rhythm control 2) Start PO flecainide 3) Coumadin, maintain INR 2-3 4) Start PO digoxin with aspirin 5) Only observation 6) Catheter ablation for AF Arrhythmia Center, KUMC

3 1, M/66

4 Pharmacological Management of Patients With Recurrent Persistent or Permanent AF Recurrent Persistent AF Permanent AF Minimal or no symptoms Disabling symptoms in AF Anticoagulation and rate control as needed Anticoagulation and rate control as needed Anticoagulation and rate control Antiarrhythmic drug therapy Electrical cardioversion as needed Continue anticoagulation as needed and therapy to maintain sinus rhythm

5 Risk Factors for Ischemic Stroke and Systemic Embolism In Patients with Nonvalvular AF Risk Factors (vs. Control Groups) Previous stroke or TIA History of hypertension Congestive heart failure Advanced age (continuous, per decade) Diabetes mellitus Coronary artery disease Relative Risk

6 JAMA 2001;285:2864 CHADS 2 Congestive Heart Failure 1 point Hypertension 1 point Age 1 point Diabetes 1 point Stroke or TIA 2 points Score 3 3 identifies high risk ( 4( 4 per 100 patient-years years) ) of stroke: The rest are moderate (>1 to 2.9) or low (<1) risk.

7 Incidence of Thromboembolism in AF 4.8 Elderly PAF * 2.5 Elderly CAF * 1.3 Young PAF *:: p<0.01 all ischemic strokes(%yr) Brain embolism(%yr)

8 A Main Finding of Rate Vs. Rhythm Trials Incidence of Ischemic Stroke AFFIRM RACE STAF PIAF 1.28( ) 2.25( ) 3.01( ) 4.92( ) TOTAL 1.35( ) P= Rhythm control better Rhythm control worse

9 A Main Finding of Rate vs. Rhythm Trials Unless contraindications exist, all patients with AF and risk factors for embolic complications should be anticoagulated.

10 1 66, 3 ( 78 ).? 1) DC cardioversion for rhythm control 2) Start PO flecainide 3) Coumadin, maintain INR 2-3 4) Start PO digoxin with aspirin 5) Only observation 6) Catheter ablation for AF Arrhythmia Center, KUMC

11 2 52, 5 (CCB) Arrhythmia Center, KUMC

12 Case #2, 52, ECG at ER

13 2 digoxin 0.25 mg, verapamil 5 mg 2. 1., 24,.? 1) Maintain PO Propafenone PO daily 2) Change CCB to Beta-blocker PO 3) Catheter ablation for atrial fibrillation 4) Anticogulation with warfarin PO 5) Flecainide PO a single oral dose ( pill( pill-in-the-pocket ) Arrhythmia Center, KUMC

14 Outpatient Treatment of Recent-Onset Atrial Fibrillation With the Pill-in-the-Pocket Approach Alboni P, et al. NEJM 2004;351: Flecainide PO (300 mg or 200 mg, if BW > or < 70kg) Propafenone PO (600 mg or 450 mg)

15 Outpatient Treatment of Recent-Onset Atrial Fibrillation With the Pill-in-the-Pocket Approach Alboni P, et al. NEJM 2004;351: Successful in 94% within minutes. Adverse effects: 7% atrial flutter, AF with RVR non-cardiac effects: nausea, asthenia, and vertigo Monthly visits to ER and hospitalization were significantly lower during F/U.

16 Outpatient Treatment of Recent-Onset Atrial Fibrillation With the Pill-in-the-Pocket Approach Alboni P, et al. NEJM 2004;351: Inclusion criteria: 1) yrs old 2) Recent onset of AF: <48 hours 3) Hemodynamically tolerable 4) Mean HR > 70 bpm 5) SBP > 100 mmhg 6) 1-12 episodes/previous yr

17 Outpatient Treatment of Recent-Onset Atrial Fibrillation With the Pill-in-the-Pocket Approach Alboni P, et al. NEJM 2004;351: Exclusion criteria: Pre-excitation or BBB Hx of AF lasting > 1 week HF, CMP, VHD Brady-tachy syndrome Previous Hx of stroke Long QT interval Brugada syndrome

18 51, 2. Flecainide 100 mg bid Propafenone 300 mg bid 5. Arrhythmia Center, KUMC

19 24.? 1) Quinidine PO 2) Catheter ablation for AF 3) Amiodarone PO 4) Pacemaker implantation (Dynamic atrial overdrive) + Amiodarone PO 5) Anticogulation with warfarin PO Arrhythmia Center, KUMC

20 Case #3, M/51

21 Case #3, M/51

22 Case #3, M/51

23 Diagnosis: Tachycardia-Bradycardia Syndrome a. Pacemaker Implantation + b. Catheter ablation for AF

24 Case #3, M/51 Circumferential PVs Ablation RSPV LSPV LSPV LAA LIPV RIPV LIPV LAA

25 Case #3, M/51 4 PVs Isolation Confirmed by Elimination of PVPs LAO LAO LSPV RAO RSPV LAO RSPV RIPV

26 Case #3, M/51 4 PVs Isolation Confirmed by Elimination of PVPs Before After * *

27 Case #3, M/51 Holter After Catheter Ablation-post 12 months

28 Reverse remodeling of sinus node function after catheter ablation of AF in patients with prolonged sinus pauses. Hocini M, Haissaguerre M. Circulation ;108(10): N=20, PAF and prolonged sinus pauses ( 3 s) on termination of AF. After AF ablation, there was a significant improvement of sinus node function. The CSNRT decreased in all patients (P=0.019). At 26.0+/-17.6 Ms, 18 patients (85%) had no recurrence of AF, with no symptoms attributable to sinus pauses on ambulatory monitoring. Two patients had infrequent episodes of AF, 1 requiring PM implantation.

29 4 77, 5 (NYHA III). Holter 3 sinus arrest 2..? 1) Propafenone PO 2) Warfarin PO 3) Catheter ablation for AT/AF 4) Pacemaker implantation 5) Aminophylline PO Arrhythmia Center, KUMC

30 Case #4, F/77

31 Case #4 F/77

32 Case #4, F/77 Holter Holter,, no Sxs

33 Case #4 F/77 Chest discomfort and Pre-syncope 5,820 ms

34 Case #4, F/77 Holter Holter,, Dizziness 4,610 ms

35 Case #4, F/77 SNRT: 4508 ms

36 Case #4, F/77 Intermittent AF (lasting 48 hrs) and AT, Sinus pause (> 3 s) was not preceded by AF or AT Class I indication of pacemaker

37 4? 1) Propafenone PO 2) Warfarin PO 3) Catheter ablation for AT/AF 4) Pacemaker implantation 5) Aminophylline PO Arrhythmia Center, KUMC

38 Pacemaker with Dual-Site Atrial Pacing RAA RAA CSos RVA CSos RVA

39 Follow up days Pacemaker with Dual-Site Atrial Pacing 100 Free of AF (%) P=0.02 Dual-site right atrial pacing Single-site atrial pacing 40 P< Before pacing

40 Is Low Atrial Septal Pacing Effective For Prevention of AF? Prevention of Atrial Fibrillation by Overdrive Atrial Septum Stimulation

41 Rationale OASES Study SR RA IAS Interatrial activation time SR: 97,7 26,5 msec. RA pace: 136,3 34,8 msec. IAS pace: 17,3 13,3 msec. Padeletti et al. J intervent. Card. Electrophysiology 1999 Posterior triangle of Koch

42 OASES AF Burden results AF burden (min AF/ day) P= P= RAA LAS CONTROL 10 0 DAO OFF DAO ON

43 OASES AF Burden results 80 ns AF burden (min AF/ day) P = RAA LAS CONTROL 10 0 DAO OFF DAO ON

44 DDDR (Low Atrial Septal Pacing with RV High Septal Pacing) CSos CSos RAO30 LAO30

45 RAO30 LAO30 Bachmann s Bundle Pacing is Effective for Prevention of AF Paced P wave shortening Bachmann s s Bundle BB pacing BB pacing

46 Patients group Risk factor Estimated risk Recommendation Age < 65 Present High Warfarin Absent Low Aspirin or nothing Age Present High Warfarin Absent Low Warfarin or aspirin Age >75 Present High Warfarin Absent Low Warfarin

47 Recommendations: Anticoagulation for AF Clinical Background Rheumatic heart disease, age < 75 yr. Lone atrial fibrillation, age < 65 yr. High risk, age < 75 yr. High risk, age > 75 yr. Patients with major contraindications to warfarin: Treatment Warfarin (INR ) ASA 325 mg/day Warfarin (INR ) Warfarin (INR ) ASA 325 mg/day

48 Arrhythmia Center, KUMC

49 Case #5, M/38 Baseline ECG

50 Case #5, M/38 2-D Echocardiography

51 5 25%. 72. ( )? 1) ACEI or ARB + Aldosterone antagonist + Warfarin PO 2) Propafenone PO + Warfarin PO 3) Pacemaker Implantation with His ablation 4) Catheter ablation for AF 5) Digoxin + Diuretics + Aspirin PO 6) DC cardioversion + Amiodarone + Warfarin PO 7) ARB only for BP control Arrhythmia Center, KUMC

52 5, M/38 ACEI + Aldosterone antagonist + Warfarin PO for 6 weeks DC cardioversion after TEE No LA thrombi/sec on TEE, PT: INR 2.4 DC AF NSR

53 Anticoagulation During Cardioversion AF reguiring cardioversion Yes Yes No Clinically urgent No AF < 24 hr No TEE available Yes LA thrombus No yes Heparin and proceed Warfarin and defer 3 weeks

54 Assessment of Cardioversion Using Transesophageal Echocardiography TEE: 619, non-tee: 603 Embolism 5 (0.8%) vs. 3 (0.5%) Hemorrhage 18 (2.9 %) vs. 33 (5.5 %) P=0.03 Successful restoration of SR 440 (71.1%) vs. 393 (65.2%) P=0.03 N Engl J Med May 10;344(19):

55 5, M/38 Post-CV Maintain PO Amiodarone Post-CV 4 weeks, EF 48%

56 5, M/38 Recurred AF post-cv 4 months, Amiodarone + Warfarin PO accompanied by chest fluttering & SOB

57 M/38, 1) Recurred Persistent AF post-cv 4 months 2) Symptomatic 3) LV dysfunction (EF:30%) 4) Amiodarone + ACEI+ Warfarin (INR:2.2) 1) Amiodarone dose 2) Change to class Ic agents 3) Rate control with digoxin and/or verapamil 4) DC Cardioversion 5) Catheter ablation for AF

58 Is Rhythm Control really better than Rate Control for relief of symptoms with fewer adverse effects and improved survival?

59 Trial of Rate vs. Rhythm Control PIAF RACE AFFIRM STAF N age AF F/U Persistent <1 yr 1.0 yr Persistent 2.3 yr 4, Persistent 3.5 yr (First onset AF 35.5%) Persistent < 2 yr 19.6 M

60 AFFIRM Atrial Fibrillation Follow-up Investigation of Rhythm Management N Engl J Med 2002;347:

61 AFFIRM Rhythm-control strategy offered no survival advantage over the ratecontrol and that there were potential advantages, such as lower risk of adverse drug effects, with the ratecontrol approach.

62 AFFIRM Does sinus rhythm offer no survival advantage over the atrial fibrillation?

63 AFFIRM On-treatment analysis Circulation. 2004;109: Survival Better Survival Worse Sinus Rhythm 0.53( ) Warfarin use Digoxin use Rhythm-control drug use 0.50 ( ) 1.42 ( ) 1.49 ( ) HR

64 Association of Sinus Rhythm but not AADs with improved survival currently available AADs are neither highly efficacious nor completely safe.

65 Non-Pharmacologic Therapy in AFFIRM Rate Control Rhythm Control Catheter AVN ablation: 5.2% (n=105) Catheter ablation: 0.7%(n=14) Maze procedure: 0.2%(n=4) NEJM 347:23: , 33, 2002

Arrhythmia Center, KUMC www.korea-heartrhythm.

66 Arrhythmia Center, KUMC Negative aspects of rhythm control Include 1) the poor efficacy of the AADs 2) the potential to cause adverse effects 3) low incidence of non- pharmacologic therapy

67 58 with CHF and a LVEF <45 % undergoing ablation for AF 58 patients without CHF undergoing ablation for AF:control

68 Improvement in LV Function and Dimensions After Ablation in Patients with CHF A EF(%) P<0.001 P<0.001 P<0.001 P<0.001 B FS (%) LV Fractional Shortening (%) P<0.001 P<0.001 P<0.001 P<0.001 Month Month C LV End-Diastolic Diameter (mm) P=0.001 P=0.03 P=0.02 P=0.001 D LV End-Systolic Diameter (mm) P<0.001 P<0.001 P=0.001 P=0.001 Month Month

69 Month Effect of Concurrent Structural Heart Disease and Rate Control before Ablation on LV Function after Ablation among Patients with CHF A LV Ejection Fraction (%) No concurrent heart disease Concurrent heart disease P<0.001 P<0.001 Month C LV Ejection Fraction (%) Inadequate Rate control Adequate rate control P<0.001 P<0.001

70 Catheter Ablation for AF in CHF Restoration and maintenance of SR by catheter ablation without the use of drugs in patients with CHF and AF significantly improve cardiac function, symptoms, exercise capacity, and QOL. Hsu L-F, et al. NEJM 2004;351:2373

71 5, M/38 Catheter Ablation for AF 4 LA-PV Junctions and Roof Linear Ablation

72 5, M/38 Immediate Before RFCA EF 25% Post-RFCA 12 Months EF 55%

73 5, M/38 Post-RFCA Follow Up No Symptomatic Arrhythmias No AF on F/U Holter Stop Warfarin Stop Amiodarone (in 9 months)

74 Catheter Ablation of AF in KUMC 2003, , 3 Follow-up for months AF-free 78.4% 80.6%* 75.0%* PAF CAF *16% on AAD *27% on AAD

75 Arrhythmia Center, KUMC Conclusions 1)?? Anticoagulation for high risk patients., LV dysfunction 2) 1 1-2? Pill-in-the-pocket approach 3) -? Effective rhythm control: Catheter ablation for AF

Arrhythmia Center, KUMC www.korea-heartrhythm.com 4) 75?

76 Arrhythmia Center, KUMC 4) 75? Pacemaker implantation, Pacing site: low septal or BB Anticoagulation, INR: )? Rhythm control: DC cardioversion + Optimal drug therapy Catheter ablation

81 F Epigastric discomfort after meals for 3 hours

Interesting EKG CASE 1-1 81 F Epigastric discomfort after meals for 3 hours 05, Cho SY, #3907730 Tn-T 0.01 ng/ml CK-MB 2.1 ng/ml BP 180/130 mmhg CASE 1-2 After 20 minutes 05, Cho SY, #3907730 CASE 1-3