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1 Vol.13 No ISSN

6 Copyright 2011 Cardiovascular Update Editorial Board. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. This publication is published by MMK Co., Ltd. AP-CVUP-11-01

7 Continuing Medical Education inquiry@mmkgroup.co.kr

9 TOPIC TOPIC TOPIC TOPIC 4. 30

10 SECTION TOPIC 1 10 Cardiovascular Update

11 Cardiovascular Update 11

12 SECTION TOPIC 1 12 Cardiovascular Update

13 Cardiovascular Update 13

14 SECTION TOPIC 1 1. Kim JS, Ryu JC, Joo SB, et al. Usefulness of headup tilt test in adults with syncope or presyncope of unexplained origin. Korean Circ J 1996;26: Oh JH, Kim JS, Kwon HC, et al. Predictors of positive head-up tilt test in patients with suspected neurocardiogenic syncope or presyncope. Pacing Clin Electrophysiol 2003;26: Shin DH, Kim JS, Park JW, et al. The use of an implantable loop recorders in patients with syncope of unknown origin. Korean Circ J 2008;38: Brignole M, Croci F, Menozzi C, et al. Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope. J Am Coll Cardiol 2002;40: Krediet CT, van Dijk N, Linzer M, van Lieshout JJ, Wieling W. Management of vasovagal syncope: controlling or aborting faints by leg crossing and muscle tensing. Circulation 2002;106: Madrid AH, Ortega J, Rebollo JG, et al. Lack of efficacy of atenolol for the prevention of neutrally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study. J Am Coll Cardiol 2001;37: The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Developed in collaboration with, European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), and Heart Rhythm Society (HRS). Eur Heart J 2009;30: Connolly SJ, Sheldon R, Thorpe KE, et al. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA 2003;289: On YK, Park JW, Huh J, Kim JS. Is home orthostatic self-training effective in preventing neurally mediated syncope? A prospective and randomized study. Pacing Clin Electrophysiol 2007;30: , p Cardiovascular Update

15 Anticoagulation Rate control First documented Antiarrhythmic drugs Cardioversion Ablation AF Silent Paroxysmal D 1wk Persistent 1 wk<d <1 yr Long-standing persistent Permanent AF; atrial fibrillation, D; duration, wk; week, yr; year Cardiovascular Update 15

16 SECTION TOPIC 2 Appropriate antithrombotic therapy Paroxysmal Persistent Permanent Long-standing persistent Rhythm control Remains symptomatic Rate control Failure of rhythm control 16 Cardiovascular Update

17 INR; international normalized ratio Cardiovascular Update 17

18 SECTION TOPIC 2 ACS; acute coronary syndrome, BMS; bare metal stent, DES; drug eluting stent 18 Cardiovascular Update

19 Atrial fibrillation Inactive lifestyle Active lifestyle Associated disease None or hypertension Heart failure COPD Digitalis -blocker Diltiazem Verapamil Digitalis -blocker Digitalis Diltiazem Verapamil Digitalis I-selective blockres COPD; chronic obstructive pulmonary disease Cardiovascular Update 19

20 SECTION TOPIC 2 Relevant underlying heart disease No or minimal heart disease (including HT without LVH) CHF CAD HT with LVH Paroxysmal AF Paroxysmal AF NYHA III/IV or unstable NYHA II Stable NYHA I/II Dronedarone Dronedarone Sotalol Dronedarone Dronedarone Flecainide Propafenone Sotalol Catheter ablation for AF Amiodarone Catheter ablation for AF Amiodarone AF; atrial fibrillation, CAD; coronary artery disease, CHF; congestive heart failure, HRS; Heart Rhythm Society, HT; hypertension, LVH; left ventricular hypertrophy, NYHA; New York Heart Association 20 Cardiovascular Update

21 Cardiovascular Update 21

22 SECTION TOPIC 2 1. Guidelines for the management of atrial fibrillation. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). European Heart Journal 2010;31: ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline): A Report of the American College of Cardiology Foundation /American Heart Association Task Force on Practice Guidelines. Circulation 2011;123: ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Circulation 2006;114; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361: Califf, R et al. Stroke prevention using the oral direct factor Xa inhibitor rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation AHA ATHENA Investigators. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009;360: HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007;4: RACE II Investigators. Lenient versus Strict Rate Control in Patients with Atrial Fibrillation. N Engl J Med 2010; 362: Cardiovascular Update

23 Cardiovascular Update 23

24 SECTION TOPIC 3 Study name Statistics for each study Risk ratio and 95% CI Risk ratio Lower limit Upper limit Z-value p-value Thai study Natale et al APAF study CACAF study Morady et al A B C 24 Cardiovascular Update

25 AF; atrial fibrillation, LA; left atrium Cardiovascular Update 25

$SECTION TOPIC 3 A B LSPV RSPV LIPV LA RA RIPV PA view NH CFAE; complex fractionated atrial electrogram, LA; left atrium, LIPV; left inferior pulmonary vein, LSPV;$

26 SECTION TOPIC 3 A B LSPV RSPV LIPV LA RA RIPV PA view NH CFAE; complex fractionated atrial electrogram, LA; left atrium, LIPV; left inferior pulmonary vein, LSPV; left superior pulmonary vein, PA; posterior-anterior, RA; right atrium, RIPV; right inferior pulmonary vein, RSPV; right superior pulmonary vein 26 Cardiovascular Update

1. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982;306:1018-1022. 2. The AFFIRM Investigators.

27 1. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982;306: The AFFIRM Investigators. Relationships between sinus rhythm, treatment, and survival in the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. Circulation 2004;109: Zimetbaum PJ, Josephson ME. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005;353: ; author reply Chandhok S, Schwartzman D. Amiodarone therapy for atrial rhythm control: insights gained from a single center experience. J Cardiovasc Electrophysiol 2007;18: Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA 303: Pappone C, Rosanio S, Augello G, et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized longterm study. J Am Coll Cardiol 2003;42: Nademanee K, Schwab MC, Kosar EM, et al. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J Am Coll Cardiol 2008;51: Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and Plane of maximum diameter distal to ostium Fixation barbs engage LAA wall LAA; left atrial appendage, RR; risk ratio Cardiovascular Update 27

28 SECTION TOPIC 3 safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2003: Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339: Perez-Lugones A, McMahon JT, Ratliff NB, et al. Evidence of specialized conduction cells in human pulmonary veins of patients with atrial fibrillation. J Cardiovasc Electrophysiol 2003;14: Nademanee K, McKenzie J, Kosar E, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004;43: Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009;374: Cardiovascular Update

29 Cardiovascular Update 29

30 SECTION TOPIC 4 30 Cardiovascular Update

31 CHF; congestive heart failure, HCMP; hypertrophic cardiomyopathy, DCMP; dilated cardiomyopathy, ICMP; ischemic cardiomyopathy, MI; myocardial infarction, VF; ventricular fibrillation, VT; ventricular tachycardia Cardiovascular Update 31

32 SECTION TOPIC CRT-D CRT-P CRT-D; cardiac resynchronization therapy-defibrillator, CRT-P; CRT-pacemaker CHF; congestive heart failure, HCMP; hypertrophic cardiomyopathy, DCMP; dilated cardiomyopathy, ICMP; ischemic cardiomyopathy, VF; ventricular fibrillation, VT; ventricular tachycardia 32 Cardiovascular Update

33 Class I ACC; American College of Cardiology, AHA; American Heart Association, HRS; Heart Rhythm Society, ICD; implantable cardioverter defibrillator, LVEF; left ventricular ejection fraction, NYHA; New York Heart Association, VF; ventricular fibrillation, VT; ventricular tachycardia EF; ejection fraction, EPS; electro-physiological study, NYHA; New York Heart Association Cardiovascular Update 33

34 SECTION TOPIC 4 1. Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study. Eur Heart J 2000;21: Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996;335: Buxton AE, Lee KL, Fisher JD, et al. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med 1999;341: Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346: Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005;352: Solomon SD, Zelenkofske S, McMurray JJ, et al. Sudden death in patients with myocardial infarction and left ventricular dysfunction, heart failure, or both. N Engl J Med 2005;352: Hohnloser SH, Kuck KH, Dorian P, et al. Prophylactic use of an implantable cardioverterdefibrillator after acute myocardial infarction. N Engl J Med 2004;351: Tanno K, Miyoshi F, Watanabe N, et al. Are the MADIT II criteria for ICD implantation appropriate for Japanese patients? Circ J 2005; 69: Siu CW, Pong V, Ho HH, et al. Are MADIT II ACE; angiotensin converting enzyme, CRT; cardiac resynchronization therapy, NYHA; New York Heart Association 34 Cardiovascular Update

35 criteria for implantable cardioverter defibrillator implantation appropriate for Chinese patients? J Cardiovasc Electrophysiol 2010;21: Moss AJ, Hall WJ, Cannom DS, et al. Cardiacresynchronization therapy for the prevention of heart-failure events. N Engl J Med 2009;361: Cardiovascular Update 35

36 Cardiovascular Update

37 Cardiovascular Update

38 Cardiovascular Update

39 THE MOST ADVANCED CONTINUING MEDICAL EDUCATION SERVICE VOL 1 NO VOL 1 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 3 NO VOL 3 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO

40 THE MOST ADVANCED CONTINUING MEDICAL EDUCATION SERVICE VOL 11 NO VOL 12 NO VOL 12 NO VOL 12 NO VOL 12 NO VOL 12 NO VOL 12 NO VOL 13 NO VOL 13 NO

43 아스트라제네카 아타칸 팀 혈압치료의 아타칸플러스 POWER 강력한 혈압강하 효과 PROTECTION 다양한 장기보호 효과 PREVENTION 고령 ISH환자에서 뇌졸중 위험 감소 1,2 3,4,5,6,7,8 * ISH : Isolated Systolic Hypertension 1. Elmfeldt D et al. Blood Press 2002;11: Bönner, Fuchs. Curr Med Res Opin 2004; 20: McMurray et al. Lancet 2003; 362: Mcmurray J et al. Am Heart J 2006; 151: Ogihara T. CASE-J study. Presented at the ISH, Oct Mogensen CE, BMJ 2000;321: Rossing K et al. Diabetes Care 2003; 26: Susan C Fagan et al. J Hypertens 2006; 24: Papademetrious V et al. JACC 2004;44: 아타칸플러스 성분 함량 : 아타칸플러스 1정중 칸데살탄 실렉세틸 16mg, 히드로클로로치아짓 12.5mg 효능 효과 : 개별 성분 치료로 효과가 충분치 않은 본태성 고혈압 용법 용량 : 1일 1회 1정 복용. 본제로 전환하기 전에 먼저 칸데살탄 실렉세틸의 용량을 조절하여야 하며, 임상적으로 적절할 때에는 단일요법으로부터 본제로 직접적인 전환을 고려할 수 있음 금 기 : 심각한 신손상 환자(크레아티닌 클리어런스 30ml/min/1.73 BSA이하), 중증의 간손상 환자, 담즙울체 환자 주 의 : 경증-중등증의 간손상 환자, 고령자 혈압치료의 서울시 강남구 대치 3동 해성 2빌딩 11층 TEL : (02) FAX : (02) 아타칸플러스 정은 장기보호 효과 및 뇌졸중 위험 감소에 대해 적응증을 가지고 있지 않습니다. 한국아스트라제네카는 승인되지 않은 적응증에 대한 처방을 권장하지 않습니다. 보다 자세한 정보는 한국 아스트라제네카 메디칼부 ( )로 문의하시기 바랍니다. P ( )-V1.0

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13.ÀÇÇÐ°�ÁÂb61è¿µÈÆ837~845’ J KMA Continuing Education Column Catheter Ablation of Atrial Fibrillation Young Hoon Kim, MD Division of Cardiology, Korea University College of Medicine E mail : yhkmd@unitel.co.kr J Korean Med Assoc