Af guidelines 2014
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AF GUIDELINES
DR.ANKIT JAIN
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A
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AF—Classification
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MECHANISM OF AF
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Risk Factors and Biomarkers for AF
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Clinical evaluation
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Investigations
• All patients with AF should have a 2D ECHO to detect underlying structural heart disease, assess cardiac function, and evaluate atrial size
• Laboratory evaluation Electrolytes, thyroid, renal, and hepatic function, and a blood count
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TEE
• TEE is the most sensitive and specific technique to detect LA
• Can be used to guide the timing o cardioversion or catheter ablation procedures
• Can identify features with an increased risk of LA thrombus formation Reduced LAA flow velocity, spontaneous LA contrast
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Risk Stratification Schemes (CHADS2, CHA2DS2-VASc, and HAS-BLED)1. CHADS2 CHF, HTN , Age ≥75 years, DM, Prior Stroke or
TIA or Embolism
2. CHA2DS2-VASc CHF, HTN, Age ≥75 years (doubled), DM, Prior Stroke or TIA or Embolism (doubled), Vascular disease, Age 65 to74 years, Sex category
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LIMITATIONS
• limitation of the CHADS2 score is that a CHADS2 score of 1 is considered an “intermediate” risk and those at lowest risk may not be well identified
• CHA2DS2-VASc index better discriminated stroke risk among subjects with a baseline CHADS2 score of 0 to 1 with an improved predictive ability
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BLEEDING SCORE
• HAS-BLED • HTN (SBP>160 mmHg), abnormal liver or renal
function, history of stroke or bleeding, labile INRs, elderly age (age >65 years), drugs that promote bleeding, or excess alcohol
• Score of ≥3 indicates potentially “high risk” for bleeding
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STROKE RISK
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Risk-Based Antithrombotic Therapy: Recommendations
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Risk-Based Antithrombotic Therapy: Recommendations
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Cardiac Surgery—LAA Occlusion/Excision
Class IIb• Surgical excision of the LAA may be considered in
patients undergoing cardiac surgery
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Rate Control: Recommendations
• The optimal heart rate targets for rate control are controversial
• The target used in trials were resting heart rate of either ≤80 bpm or averaging ≤100 bpm on ambulatory monitoring
• Without a rate >100% of the maximum age-adjusted predicted exercise heart rate
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Rate Control: Recommendations
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Rate Control: Recommendations
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Rhythm Control
• Persistent symptoms associated with AF is the most compelling indication for a rhythm-control strategy
• Difficulty in achieving adequate rate control• Younger age• Tachycardia-mediated cardiomyopathy• First episode of AF, AF that is precipitated by an acute illness,
and patient preference• AF progresses from paroxysmal to persistent and
subsequently results in electrical and structural remodeling that becomes irreversible with time
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Thromboembolism prevention
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TEE
• TEE guidance is an alternative to 3 weeks of anticoagulation prior to cardioversion
• Therapeutic anticoagulation is achieved, followed by a TEE; if no thrombus is seen (including in the LAA), cardioversion is performed and anticoagulation is continued for a ≥4 weeks
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Thromboembolism prevention
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Direct-current Cardioversion
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C/I
• Elective cardioversion should not be performed in patients with
• Digoxin toxicity• Severe hypokalemia
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PHARMECOLOGICAL CARDIOVERSION
• Drugs are effective when initiated within 7 days after the onset of an episode of AF
• In recent onset AF IV ibutilide restored sinus rhythm in about 50% of patients with an average conversion time of <30 minutes
• The rates of success were higher in those patients with atrial flutter than in those with AF
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CONTD..
• The major risk is excessive QT prolongation,• Polymorphic ventricular tachycardia, in up to 3%- 4%
patients.• ECG monitoring should be continued for ≥4 hours after
administration• Ibutilide should be avoided in patients with QT prolongation,
marked hypokalemia, or a very low ejection fraction (EF) (<30%)
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CONTD..
• An oral dose of flecainide or propafenone can be used as a “pill-in-the-pocket”
• Termination of AF may be associated with bradycardia owing to sinus node depression Initial conversion trial should be done in hospital
• A beta blocker or CCB should be administered ≥30 minutes before administering IC agent to prevent a rapid ventricular response During flutter
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Pharmacological cardioversion
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DRUG DOSE
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Drugs for Preventing AF and Maintaining Sinus Rhythm
• Before antiarrhythmic drug treatment is initiated, reversible precipitants of AF should be identified and corrected
• After the first episode of AF that resolves, it is reasonable to address the underlying causes of AF and to not initiate antiarrhythmic drug treatment until AF recurred
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CONTD..
• Decisions regarding anticoagulation should be based on the patient’s individual stroke risk profile and not on the response to antiarrhythmic drug therapy
• Antiarrhythmic drug efficacy is modest and asymptomatic AF recurrences are common
• So a rhythm-control strategy should not result in cessation of antithrombotic therapy, rate control therapy, or treatment of underlying heart disease
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CLASS 1
• 1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended
• 2. The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm Amiodarone , Dofetilide , Dronedarone , Flecainide ,Propafenone ,Sotalol
• 3. Due to toxicites amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated
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Class IIa
• A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardia-induced cardiomyopathy
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Class III: Harm
• 1. Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent
• 2. Dronedarone should not be used for treatment of AF in patients with New York Heart Association (NYHA) class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks
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DRUGS FOR RHYTHM CONTROL
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Primary prevention of AFwith “upstream” therapy
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AF Catheter Ablation to Maintain Sinus Rhythm
• Class I
1) AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired ( (Level of Evidence: A)
2) Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended
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CLASS IIA
• AF catheter ablation is reasonable for selected patients with
symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (Level ofEvidence:A)
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CLASS IIB
1. AF catheter ablation may be considered for symptomatic
long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired (Level of Evidence: B)
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Class III: Harm
1. AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C)
2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C)
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Surgery Maze Procedures: Recommendations
Class IIaAn AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications. (Level of Evidence: C)
Class IIbA stand-alone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches
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Summary of Recommendations for Specific Patient Groups and AF
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Hypertrophic cardiomyopathy
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AF complicating ACS
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WPW and pre-excitation syndromes
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HEART FALIURE
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Post cardiothoracic surgery
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CONTD..
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THANK YOU