de la Fibrillation Auriculaire en Pratique de Ville Samer Nasr MD Mount Lebanon Hospital Classification Lone atrial fibrillation Younger than 60 years old No clinical or echo evidence of cardiopulmonary disease ID: 360707
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Slide1
Réduction de la Fibrillation Auriculaire en Pratique de Ville
Samer
Nasr, M.D.
Mount Lebanon Hospital.Slide2Slide3
Classification Lone atrial fibrillation:
Younger than 60 years old.
No clinical or echo evidence of cardiopulmonary disease.
Favorable prognosis.
Thromboembolism
usually not an issue.
Substrate related
atrial
fibrillation.
ETOH Hyperthyroidism HTN
Surgery Metabolic disorders
Cardiomyopathy
MI Obesity Sleep apnea
Pericarditis
Valvular
disease
Myocarditis
Heart failure
PE CADSlide4
Substrate Related Atrial Fibrillation.Slide5
Substrate Related Atrial Fibrillation. Slide6
Substrate Related Atrial Fibrillation.Slide7
AF: Treatment Options
Rhythm normalization
AA
drugs
Ia
Ic
III
New
AAd
Cardioversion
Non AA
drugs
AF Ablation
Rate
normalization
AV node blockers
BB -
DIG
CA -
… AV node ablation
Stroke prevention
Pharmacologic
AC ++ Aspirin New AT drugsNonpharmacologicRemoval/isolation LA appendage
Anti –
coagulation
INR: 2-3Slide8
Lone Atrial Fibrillation:Outpatient Conversion to NSR.Slide9
Lone Atrial FibrillationRate of progression to permanent
atrial
fibrillation.
PrognosisSlide10
First Episode
Paroxysmal (recurrent)
Permanent
LoNE
No recurrenceSlide11
Probability of AF recurrence after the
first episode
the Canadian Registry of Atrial Fibrillation
Am Heart J 2005;149:489- 96
757 patientsSlide12
UK
Registry .
BMC Cardiovascular Disorders 2005, 5:20
525 patients
Progressing to chronic AF after the
first episodeSlide13
Olmsted County
Circulation. 2007;115:3050-3056
30-Year Follow-Up
Long-term progression of paroxysmal or persistent
lone AF
to permanent AFSlide14
=>
the risk of progression to permanent
atrial
fibrillation
is around 20%
in young patients
=>
Up to 30% of patients will not recur their AF after the first episodeSlide15
UK
Registry
BMC Cardiovascular Disorders 2005, 5:20
525 patients
5 y F-U
Mortality rate in paroxysmal
atrial
fibrillation
*
Relative risk estimated by Cox regression model, including age, sex, smoking, heart failure, ischaemic heart disease, hypertension, cerebrovascular disease and diabetes.Slide16
Olmsted CountyCirculation. 2007;115:3050-3056
Long-term observed survival in
lone AF
30-Year Follow-UpSlide17
=>
Patients with lone
atrial
fibrillation have a normal life expectancy.
=>
Comorbidities
significantly modulate AF prognosis and complications: hypertension, diabetes, heart failure, and advancing age …Slide18
Long term efficacy of
Anti-arrhythmic drugs Slide19Slide20
Roy D, et al. New Engl J Med. 2000;342:913–920.
CTAF Study: % of Patients Remaining Free of Recurrence of AF
0.0
0
100
200
300
400
500
600
Days of Follow-up
Patients Without Recurrence (%)
20
40
60
80
100
Amiodarone (n = 201)
Sotalol (n = 101)
Propafenone (n = 101)Slide21
Adverse Effects of Oral
Amiodarone
Zimetbaum
P. N
Engl
J Med 2007;356:935-941Slide22
Treatment of Paroxysmal Atrial Fibrillation in Outpatient Setting.
Out patient management of PAF can be performed using:
Pill-in- the-pocket.
Amiodarone
.
Dronaderone
.Slide23
Pill-in-the-pocketA beta-blocker or NDHP Ca-blocker.
Half an hour later ; if symptoms persist:
Propafenone
:
600 mg if > 70kg
450mg if <70 KG
Flecanide
:
300 mg if >70 kg.
200 mg if < 70 kg.
Only once in 24 hour period
.Slide24
Pill-in-the-Pocket 268 patients presenting to ER with AF. given
Flecanide
or
Propafenone
.
58 had treatment failure or side effects; excluded
Out-of-Hospital self administration of
Flecanide
or
Propafenone
studied in remaining 210.
79 percent had episodes of arrhythmias
92 % treated 36
±93 minutes after
sx
onset
Treatment succesful in 94% of episodes
.
Alboni
P, et al. NEJM, 2004;351:23.Slide25
“Pill in the Pocket” Technique
15
4.9
1.6
0
10
20
30
40
50
80
Paroxysms of AF
Emergency visits
Hospitalizations
Previous year
Pill in the Pocket treatment period
P
< 0.001
45.6
P
< 0.001
ns
59.8
54.5
60
70
Alboni P, et al.
N Engl J Med
.
2004;351:2384-2391.
episodes
per monthSlide26Slide27
… For additional safetyTreat the first episode inpatient with IC antiarrhythmics
.
Make sure
QT
interval stays unchanged with therapy.
Perform exercise stress test on therapy and document
QRS
interval stability prior to initiating pill-in-the-pocket technique.Slide28Slide29
Lone Atrial Fibrillation
Outpatient therapy of Lone AF can be performed safely and effectively if thorough patient selection with appropriate work up is performed.
QOL is The main goal of outpatient therapy.Slide30
Amiodarone in Outpatient SettingDosages and precautionsSlide31
Electrophysiological Action of
Amiodarone
Zimetbaum
P. N
Engl
J Med 2007;356:935-941Slide32
Recommendations
Baseline
screening studies should include tests of liver, thyroid, and pulmonary function as well as chest radiography.
It
is reasonable to initiate
amiodarone
therapy in the outpatient setting.Slide33
Recommendations
A slightly reduced loading dose (e.g., 600 mg per day in one dose or divided doses for 3 to 4 weeks) is
reasonable.
The patient should undergo electrocardiography weekly or should be discharged with a loop recorder to monitor heart rhythm, heart rate, and duration of the QT interval.
If conversion has not occurred by the end of the loading period, electrical
cardioversion
should be performed, followed by a reduction in the dose of
amiodarone
to 200 mg daily
.Slide34
Hohnloser. N Engl J Med 2009;360:668-78.
ATHENA study
The ATHENA Trial
A
placebo-controlled, double-blind, parallel arm
T
rial to assess the efficacy of
dronedarone
400 mg bid for the prevention of
cardiovascular
H
ospitalization
or
death
from any cause in
pati
EN
ts
with
Atrial fibrillation / atrial flutterSlide35
Dronedarone reduces Cardiovascular Death
Hohnloser. N Engl J Med 2009;360:668-78.
ATHENA study
0.0
2.5
5.0
7.5
2301
2290
2274
2250
2240
1629
1593
636
615
7
4
2327
Placebo
Placebo
Dronedarone
Months
Patients at risk
HR=0.71
P=0.034
Dronedarone
0
6
12
18
24
30
Cummulative Incidence (%)Slide36
Dronedarone reduces the incidence of
cardiovascular hospitalization or death
Hohnloser. N Engl J Med 2009;360:668-78.
ATHENA study
0
10
20
30
40
50
2301
1858
1963
1625
1776
1072
1177
385
403
3
2
2327
Placebo
Placebo
Dronedarone
Months
Patients at risk
Dronedarone
HR=0.76
P<0.001
0
6
12
18
24
30
Cummulative Incidence (%)Slide37
Dronaderone vs Amiodarone
Meta-analysis on Dronaderone vs Amiodarone: From ANDROMEDA to. DIONYSOS.
Dronaderone less effective than amiodarone for atrial fibrillation with an odds ratio of 0.5 .
Less Side Effects.
Less efficacy.
Dronaderone trades efficacy for safety.
Piccini et al, J. Am Coll Cardiol. 2009: 54:1089-1095Slide38
Conclusion:Lone
atrial
fibrillation: a benign disease.
Strict rules should apply to outpatient therapy.
Careful initial screening for underlying heart disease is imperative.
Frequent reevaluation of the substrate is a must to ensure that organic heart disease has not occurred with time.