Gianluca Botto FESC Presidente AIAC Associazione Italiana Aritmologia

Gianluca Botto, FESC Presidente AIAC Associazione Italiana Aritmologia e Cardiostimolazione FA Sintomatica e Asintomatica Epidemiologia e Rischio Clinico

Presenter Disclosure Information n Research support: Boston Scientific, Medtronic; St. Jude Medical, Bayer Healthcare, Gilead, Sanofi n Advisory Board: Biotronik, Medtronic; St. Jude Medical, MSD, Bayer Healthcare, Boehringer, Sanofi n Speaker Fees: Boston Scientific, Medtronic, St. Jude Medical, Sorin Group, Bayer Healthcare, Boehringer, BMS, Meda, MSD, Pfizer, Sanofi

Paroxysmal Atrial Fibrillation Symptomatic vs Asymptomatic a a = symptomatic PAF b c b = asymptomatic PAF c = sinus rhythm AF can be silent Courtesy of John Camm

Stroke as a First Devastating Sign of Atrial Fibrillation

Comprehensive Management Of AF Should Address The Multiple Impacts Of The Condition » In addition to stroke prevention and reduction of AF burden, successful management of AF should aim to reduce hospitalisations and CV morbidity and mortality Prevention of stroke Reduction in CV mortality Camm AJ, Eur Heart J 2012; 33: 2719 -2747 Reduction in the risk of CV- events and hospitalisations Reduction of AF burden* Qo. L Symptoms 5

Relation B/ween Symptoms and ECG Transmission in AF Vesamreddy et al. J Cardiovasc Electrophysiol 2006; 17: 134 -139

Cost-Effectiveness of Stroke Prevention Through Screening for AF Using i. Phone ECG The Search-AF Study Lowres et al. Thrombosis & Haemostasis 2014

Conversion From Symptomatic to Silent AF During AAD Rx 52 patients with PAF with 24 hour Holter No symptoms AF duration at baseline (s) AF duration on treatment (s) Symptomatic 2215 +/- 3843 16 +/- 10 HR at baseline (bpm) 126 +/- 27 HR on treatment (bpm) 82 +/- 8 No PAF on Holter After Before 22% 47% 26% 53% 78% Wolk R. Int J: Cardiol 1996; 54: 207 -211 74% 73%

Atrial Fibrillation The More You Look, The More You Find Incremental Yield of Prolonged ECG Monitoring for the Detection of AF in Pts with Cryptogenic Stroke or TIA. More intensive monitoring results in more AF detection Gladstone DJ. For the EMBRACE Invests. N Engl J Med 2014; 370: 2467 -77

AF Monitoring Options Technology Storage Continuous Electrodes < 1 minute Yes 10 on skin 24 – 48 hours Yes 3 on skin 7 – 28 days No 3 on skin Transtelephonic ECG monitoring Minutes/ day No On skin External loop recorder 7 – 28 days Yes On wrist or 2 -3 on skin Mobile cardiac outpatient monitoring (MCOT) Continuous, (<28 days) Yes 3 on skin Insertable loop recorder Continuous Yes Under skin Implanted Pacemaker, ICD Continuous Yes Implanted, PM/ICD pt. ECG Holter Event recorder Comments Only symptomatic events Discontinuous Direct transmission

AF Detection 24 -h Holter: Something Like a Disaster ■ 425 Holter ECGs after cerebral ischemic event ■ 18. 2% of all Holters in the hospital AF diagnosis 9 (2. 1%) OAC start 5 (1. 2%) Holters needed 47 85 Costs per case $9, 400 $17, 000 Number of patients Schaer B. Stroke 2004; 35: e 68 -70

Opportunistic Screening of AF Pulse vs Microlife Tech Hobbs 2592 Morgan 1099 Wiesel 405 Stergiou 73 Kearly 999 Botto GL, Russo G. 2015

Cost-Effectiveness of Stroke Prevention Through Screening for AF Using i. Phone ECG The Search-AF Study Lowres et al. Thrombosis & Haemostasis 2014

Cost-Effectiveness of Stroke Prevention Through Screening for AF Using i. Phone ECG The Search-AF Study If ECG screening was extended to general comunity the incremental cost-effectiveness would be: ■ USD 4. 066 per QALY ■ USD 20. 695 per prevention of one stroke Lowres et al. Thrombosis & Haemostasis 2014

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Acqusition of single or multiple signals Internet of things ECG and pulse wave detecting driving wheel from Toyota Courtesy of P. Guzik

Improvement of Device Technology Allows Greater Quantification of AF Burden Botto GL. JCE. 2009; 20: 241 -248

Cardiac Monitoring Set Improved Care. Link® User Interface Wireless Reveal LINQ™ ICM Simplified Implant Procedure My. Care. Link™ Patient Monitor Cellular Mobile Alerts Patient Assistant Streamlined Reports All patient and clinical data are fictitious and for demonstration purposes only

ANTIARRHYTHMIC STARTED HERE 26 -Jul-2011 20 -Oct-2010

AF Detected By Dual-Chamber Devices And Risk For Stroke Camm J, Corbucci G, Padeletti L. Am J Cardiol 2012; 110: 270 -276

ASSERT Trial: Primary Outcome 6 min n 2582 pts with SSS; HTx and no prior AF (76± 7 years, CHADS 2 score 2. 41) n goal AF > 6 min, > 190 bpm in 36% of pts; F-U 2. 8 years Healey JS. New Engl J Med 2012; 366: 120 -9 (modif. )

Incremental Cost Burden of Undiagnosed AF By Prevalence of Undiagnosed AF Turakhia MP. AJC 2015, 116: 733 -739

Atrial Fibrillation and Stroke Bread for the Brain n Asymptomatic device-detected AHRE are of clinical importance n The impact of device-detected atrial high-rate episodes and arrhythmia burden on thrombogenesis and clinical thromboembolism is attracting much interest n Thromboembolic risk is not only related to AT/AF episodes, but likely involves a complex interplay of - atrial arrhythmias - atrial myopathy - endotelial dysfunction related to comorbidity - abnormal hemostasis n The need for anticoagulation Rx is mostly depending on stroke risk factors once a low threshold of AT/AF burden is exceed rather than merely the presence/absence of AF n Cost-effectiveness of future approaches needs to be determined