Atrial Fibrillation Clinical Update Dr Amit Shah MD

Atrial Fibrillation Clinical Update Dr. Amit Shah, MD FACC Electrophysiology Cardiology Consultants of West Alabama August 21, 2018

Disclosures None Always willing to take money

Overview Clinical cases Pathophysiology Stroke prevention Rate vs Rhythm control Medication vs ablation for rhythm control Review cases New advancements & PEARLS Questions

Case #1 67 yo WM HX of CAD s/p CABG, DM, HTN Poor compliance Presented to PMD for annual visit, no symptoms Exam noted IRRRR ECG shows AF with RVR

Case #2 74 yo WF Hx of symptomatic parox AF x 5 years, DM, HTN Treated with sotalol, developed HB and has PPM Continues to have palpiations and fatigue due to sotalol On Eliquis 2. 5 mg po BID

Case#3 55 yo WM No PMH Presented for feeling funny and checks BP/HR daily and today reads 130 bpm, never had this previously No other symptoms ECG shows AF

Pathophysiology William Harvey (1578 -1657), the first to describe fibrillation of the auricles in animals in 1628. The first human ECG depicting atrial fibrillation was published by Willem Einthoven (1860 -1927) in 1906.

Pathophysiology

Atrial fibrillation Stroke Prevention strategies Rate vs rhythm control

2 2 CHADS -VA Sc

Anti-Coagulation Recommendations

Has Bled Score Bleeding risk

ELIQUIS VS ASPIRIN From: Efficacy and safety of apixaban compared with aspirin in the elderly: a subgroup analysis from the AVERROES trial Ageing. 2015; 45(1): 77 -83. doi: 10. 1093/ageing/afv 156 Ageing | © The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals. permissions@oup. com

Question #2 Rate vs Rhythm Control

Rate vs Rhythm Control

Rhythm control in CHF

Rhythm control does not confer a mortality benefit

Symptomatic Atrial Fib

Rhythm control strategy

Medical therapy for Maintenance of sinus rhythm

Rx vs Ablation CABANA trial

What is Atrial Fibrillation Ablation?

Atrial Fibrillation Ablation Surgical experience Cox Maze - 1987

Cox Maze Surgery for AF

Catheter ablation

Surgical to endovascular

Cryotherapy vs RF

CABANA

Endpoints

COURAGE Trial

Final Answer?

Case #1 67 yo WM HX of CAD s/p CABG, DM, HTN Poor compliance Presented to PMD for annual visit, no symptoms Exam noted IRRRR ECG shows AF with RVR

Case #1 Stroke Prevention strategy CHADS 2 -VASC= 4 → OAC Coumadin vs NOAC Other meds are QD so Xarelto Rate vs Rhythm control No symptoms, rate control CAD start with BB Check ECHO, TSH, ect.

Case #2 74 yo WF Hx of symptomatic parox AF x 5 years, DM, HTN Treated with sotalol, developed HB and has PPM Continues to have palpiations and fatigue due to sotalol On Eliquis 2. 5 mg po BID

Case #2 CHAD VASC = 4 → OAC (on eliquis) Rate vs rhythm control Drug refractory AF → ablation Drug side effects, try to stop sotalol

Case#3 55 yo WM No PMH Presented for feeling funny and checks BP/HR daily and today reads 130 bpm, never had this previously No other symptoms ECG shows AF

Case #3 CHAD VASC = 0 Aspirin is reasonable strategy Rate vs rhythm control Minimal symptoms Attempt TEE/DCCV and see if significant improvement Would hold on anti-arythmic agents Given young age, discussion of ablation reasonable, but no mortality benefit

Advancements in Atrial fibrillation

Watchman

Micra Pacemaker

PEARLS

Sleep Apnea

Magnesium

Coffee

Questions

The End