Current Guideline for AF Treatment - 대한내과학회

1 Current Guideline for AF Treatment Young Keun On, MD, PhD, FHRS Samsung Medical Center Sungkyunkwan University School of Medicine Case 1 59 year-old lady Sudden palpitation and breathlessness for 12 hours Remote onset 2 months ago Palpitation persisted for 1~2 hours HTN (-), DM (-) Echocardiography LVEF 67% LVESD/EDD 30/53 mm LA 42 mm LAVI 22 ml/m2 IVSd 10 mm, LVPWd 10 mm Normal LV and RV Valve : normal Great vessel : normal What Treatment strategy would you choose? control strategy control strategy with anticoagulation control strategy control strategy with anticoagulation only Classification First detected AF Permanent AF (irreversible) Persistent AF (Not self- terminating) > 7 days Paroxysmal AF (Self- terminating) 7 days (most <24hr) Recurrent : two or more episode Longstanding persistent AF: continuous AF of greater than one-year duration Diseases associated with AF Valvular Heart Disease : Rheumatic mitral disease Non-valvular HD.

2 CAD, HTN Hyperthyroidism Pulmonary thromboembolism Rhythm control for AF Pharmacologic Treatment DC cardioversion RFCA (radiofrequency catheter ablation) Maze operation Vaughan Williams Classification of Antiarrhythmic Drug Actions Type IA (block the sodium channel with intermediate recovery time) Disopyramide, Procainamide, Quinidine Type IB (block the sodium channel with rapid recovery time) Lidocaine, Mexiletine Type IC (block the sodium channel with slow recovery time) Flecainide, Moricizine, Propafenone Type II Beta-blockers ( , propranolol) Type III (prolongation of the cardiac action potential) Amiodarone, Bretylium, Dofetilide, Ibutilide, Sotalol Type IV Calcium-channel antagonists ( , verapamil and diltiazem) 2014 AHA/ACC/HRS AF Guideline Rhythm Control in AF After Medication of Propafenone 300 mg bid Atrial Fibrillation The most common cardiac arrhythmia.

3 Confers a 5-fold risk of stroke. The rate of ischemic stroke among patients with AF averages 5% per year. One of five (20%) of all strokes is attributed to AF. The risk of death from AF-related stroke is doubled. Treatment strategy of AF Prevention of thromboembolism : Antithrombotic therapy Rhythm control Rate control Prevention of thromboembolism in AF patients Vitamin K Antagonist Warfarin NOAC Anticoagulant Anti-platelet agents Aspirin +/- Clopidogrel Hart RG et al, Ann Intern Med 1999;131:492 Stroke prevention by Warfarin vs Aspirin in AF patients Stroke prevention 39% Stroke and ICH by INR in AF patients Hylek EM et al, N Engl J Med 1996;335:540 INR CHA2DS2 VASc score and stroke rate Camm AJ, et al.

4 Eur Heart J 2010 Risk factors CHF (1) HT (1) 75 yrs old (2) DM (1) Previous stroke, TIA, Thromboembolism (2) Vascular disease (1) 65~74 yrs old (1) Female (1) 02468101214160123456789 Annual stroke rate Pisters R, et al, Chest 2010 HAS-BLED bleeding risk score Bleeding risk score Hypertension (1) Abnormal renal function (1) Abnormal liver function (1) Stroke (1) Bleeding (1) Labile INRs (1) Elderly > 65 yrs old (1) Drugs (1) Alcohol (1) Hypertension: systolic blood pressure >160 mmHg Abnormal kidney function: the presence of chronic dialysis or renal transplantation or serum creatinine 200 mol/L. Abnormal liver function: chronic hepatic disease ( cirrhosis) or bilirubin >2 x upper limit of normal in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase >3 x upper limit normal).

5 Bleeding : previous bleeding history and/or predisposition to bleeding, bleeding diathesis, anemia, etc. Labile INRs : unstable/high INRs or poor time in therapeutic range ( <60%) Drugs/alcohol use : concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse Bleeding risk score Elderly > 65 yrs old (1) Stroke (1) Hypertension (1) Abnormal renal function (1) Abnormal liver function (1) Bleeding (1) Labile INRs (1) Drugs (1) Alcohol (1) CHA2DS2 VASc score vs HAS-BLED score Stroke risk factors 75 yrs old (2) Previous stroke, TIA, Thromboembolism (2) CHF (1) HTN (1) DM (1) Vascular disease (1) 65~74 yrs old (1) Female (1) Recommendations for Prevention of Thromboembolism in AF AHA/HRS 2014 OAC OAC/aspirin/No Tx No Tx Case 1 CHA2DS2 VASc score : 1 0 Female (1).

6 Lone AF HAS-BLED score : 0 What Treatment strategy would you choose? control strategy control strategy with anticoagulation control strategy control strategy with anticoagulation only Case 2 60 year-old gentleman Palpitation with chest discomfort, dizziness Drug refractory recurrent paroxysmal to persistent AF Medication Hx : propafenone, flecainide, sotalol Hypertension (+) with medication for 2 years Echocardiography Normal LV cavity size & systolic function Normal LV wall thickness No regional wall motion abnormality LVEF: 68% LVIDs/LVIDd: 27/48mm LA: 40mm LAVI: IVSd : 9mm LVPWd: 10mm E: e`: E/e`: Ao: 27mm DT: CHA2DS2 VASc score : 1 HTN HAS-BLED score : 1 HTN What Treatment strategy would you choose?

7 Control strategy control strategy with anticoagulation control strategy control strategy with anticoagulation only Nattel S, et al. Eur Heart J 2014 A conceptual model of atrial fibrillation events in relationship to underlying substrate. Both primary disease and AF-induced structural, electrical, and autonomic remodelling contribute to progression from paroxysmal to persistent AF. Recommendations for Thromboembolism Prevention in Cardioversion of AF/AFL Recommendations COR LOE With AF or atrial flutter for 48 h, or unknown duration, anticoagulate with warfarin for at least 3 weeks prior to and 4 weeks after cardioversion I B Recommendations COR LOE With AF or atrial flutter for 48 h, or unknown duration, anticoagulate with warfarin for at least 3 weeks prior to and 4 weeks after cardioversion I B With AF or atrial flutter for 48 h or unknown duration and no anticoagulation for preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion, and then cardiovert if no LA thrombus is identified.

8 Provided anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks IIa B With AF or atrial flutter 48 h, or unknown duration, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for 3 weeks prior to and 4 weeks after cardioversion IIa C 2014 AHA/ACC/HRS AF Guideline Recurrence of Atrial Fibrillation patients after DC cardioversion What Treatment strategy would you choose? control strategy control strategy with anticoagulation control strategy control strategy with anticoagulation only Recommendations for Rate Control in AF Recommendations COR LOE Control ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist for paroxysmal, persistent, or permanent AF I B A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of AF IIa B AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological management is inadequate and rhythm control is not achievable IIa B Lenient rate control strategy (resting heart rate <110 bpm)

9 May be reasonable with asymptomatic patients and LV systolic function is preserved IIb B Radiofrequency Catheter Ablation (RFCA) Radiofrequency lesion in human ventricular myocardium Initiation of Atrial Fibrillation by LSPV ectopic PAC & induction of AF AF ablation : to eliminate AF triggers to modify the susceptible substrates PV Isolation by Catheter Ablation Three dimensional map of the LA and PV Radiofrequency lesions CT angiography Indications for catheter ablation of AF Indications for catheter ablation of AF Class Level Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication Paroxysmal : Catheter ablation is recommended Persistent : Catheter ablation is reasonable Longstanding Persistent (>12 months) : Catheter ablation may be considered I IIa IIb A A B Symptomatic AF prior to initiation of antiarrhythmic drug therapy with a Class 1 or 3 antiarrhythmic agent Paroxysmal : Catheter ablation is reasonable Persistent : Catheter ablation may be considered Longstanding Persistent : Catheter ablation may be considered IIa IIb IIb B C C 2014 AHA/ACC/HRS AF Guideline .

10 (I or III) 1 6 , , (permanent) . - . 3 , Korea Reimbursement criteria for AF catheter ablation by Health Insurance Review and Assessment Service 2014. 6. 1. Case 3 68 year-old gentleman Frequent dizziness with palpitation No functional decline Hypertension (+), DM (+) Medication of HTN and DM 1 Tachycardia Bradycardia syndrome CHA2DS2 VASc score : 3 Age 68 yrs HTN DM HAS-BLED score : 2 Age 68 yrs HTN What Treatment strategy would you choose?