Περίπτωση μέσης ηλικίας ασθενή με ασυμπτωματική εμμένουσα κολπική μαρμαρυγή. Ποια είναι η ενδεδειγμένη θεραπευτική αντιμετώπιση;

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1 Περίπτωση μέσης ηλικίας ασθενή με ασυμπτωματική εμμένουσα κολπική μαρμαρυγή. Ποια είναι η ενδεδειγμένη θεραπευτική αντιμετώπιση; Λίλιαν Μάντζιαρη, MSc PhD Καρδιολόγος Επεμβατικός Ηλεκτροφυσιολόγος Ιατρικό Διαβαλκανικό Θεσσαλονίκης Επιστημονικός συνεργάτης Γ Καρδιολογικής Κλινικής ΠΓΝ Ιπποκράτειο

2 Ασυμπτωματική Εμμένουσα Μέσης ηλικίας Ποιότητα ζωής Διάρκεια ζωής

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4 Case Γυναίκα 52 ετών με εμμένουσα κολπική μαρμαρυγή- τυχαία διάγνωση Ασυμπτωματική Δεν αισθάνθηκε διαφορά στις καθημερινές δραστηριότητες μετά από ηλεκτρική ανάταξη (mod EHRA score 1) CHADS-VASc 1. Χωρίς επιπλέον παράγοντες κινδύνου εκτός του φύλου

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6 Ασυμπτωματική εμμένουσα κολπική μαρμαρυγή

7 Εμμένουσα κολπική μαρμαρυγή EF 40-50% μικρή προς μέτρια ανεπάρκεια μιτροειδούς

8 ESC guidelines for management of AF 2016

9 Diagnostic workup of atrial fibrillation patients Patients with symptoms or signs of myocardial ischaemia should undergo coronary angiography or stress testing as appropriate. In patients with AF and signs of cerebral ischaemia or stroke, computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is recommended to detect stroke and support decisions regarding acute management and long-term anticoagulation.

10 Anticoagulation: Yes or No? Χωρίς παράγοντες κινδύνου CHA2DS2-VASc 1 λόγω φύλου εμμένουσα vs παροξυσμική? Μέγεθος αριστερού κόλπου?

11 Αποφάσεις σχετικά με την αντιπηκτική αγωγή

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13 Stroke 2016;47: the summary ischemic stroke risk of 1.61% was above the threshold indicated in Eckman et al of 0.9% for NOAC but under the threshold of 1.7% for warfarin. patients with a CHA2DS2-VASc score of 1 (annual rate of 1.61%) may be eligible for a NOAC (threshold of 0.9%), but likely not warfarin (threshold of 1.7%).

14 Am J Cardiol 2015;116:1781e1788

15 Ελεγχος συχνότητας ή έλεγχος ρυθμού;

16 Έλεγχος συχνότητας Βελτιώνει τα συμπτώματα Αυξάνει το προσδόκιμο επιβίωσης Ποια είναι η ιδανική συχνότητα στόχος; Λίγα δεδομένα από μελέτες υποστηρίζουν ένα σχετικά χαλαρό έλεγχο συχνότητας με στόχο συχνότητας ηρεμίας <110/λεπτό

17 Τι είναι καλύτερο; ΚΟΛΠΙΚΗ ΜΑΡΜΑΡΥΓΉ ΦΛΕΒΟΚΟΜΒΙΚΌΣ ΡΥΘΜΟΣ

18 Κολπική μαρμαρυγή φυσική εξέλιξη

19 Η κολπική μαρμαρυγή προκαλεί καρδιακή ανεπάρκεια Progression of Device-Detected Subclinical Atrial Fibrillation and the Risk of Heart Failure

20 Η κολπική μαρμαρυγή προκαλεί άνοια;

21 Catheter ablation for asymptomatic AF?

22 October consecutive patients (mean age 62 ±13 years, 71% males) with asymptomatic LSP AF undergoing first catheter ablation were enrolled. Extended pulmonary vein antrum isolation plus ablation of complex fractionated atrial electrograms and nonpulmonary vein triggers was performed in all. After 20 ± 5 months follow up, 36 (57%) patients remained recurrence free off AAD. Of the 25 patients experiencing recurrence, 21 (84%) were symptomatic. Compared to baseline, follow up SF 36 scores improved significantly in many measures. For patients with successful ablation, physical component summary (PCS) and mental component summary (MCS) demonstrated substantial improvement. Postablation exercise study in recurrence free patients showed significant reduction in resting and peak heart rate (75 ± 11 vs. 90 ± 17 and 132 ± 20 vs ± 36, respectively, P < 0.001), increase in peak oxygen pulse (13.4 ± 3 vs ± 16 ml/beat, Δ5.5 ± 15, P = 0.001), peak VO2/kg (19.7 ± 5 to 23.4 ± 13 ml/kg/min [Δ 3.7 ± 10, P = 0.043]), and corresponding MET

23 Catheter ablation for asymptomatic AF? Management of AF - ESC guidelines 2016 There is no current indication for catheter ablation to prevent cardiovascular outcomes (or desired withdrawal of anticoagulation), or to reduce hospitalization. GAPS IN EVIDENCE (ESC 2016) Can rhythm control therapy convey a prognostic benefit in atrial fibrillation patients? The progress in rhythm control therapy (catheter ablation, new antiarrhythmic drugs) and observational long-term analyses suggest that rhythm control therapy may have a prognostic benefit in anticoagulated AF patients. Ongoing trials such as CABANA and EAST AFNET 4 will provide initial answers to this important question, but more data are needed, including trials of surgical ablation techniques.

24 Catheter ablation for AF HRS guidelines 2017 May consider catheter ablation for asymptomatic AF (but not long standing)

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26 Recurrence of Atrial Arrhythmias in the Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial Jeanne E. Poole MD, George Johnson BSEE, Kristi H. Monahan RN, Hoss Rostami BSMSE, Adam Silverstein MS, Hussein Al-Khalidi PhD, Mauri Wilson RN, Yves Rosenberg MD, MPH, Tristram D. Bahnson MD, Richard A. Robb PhD, Daniel B. Mark MD, MPH, Kerry L. Lee PhD, Douglas L. Packer MD for the CABANA Investigators and ECG Rhythm Core Lab

27 Background CABANA randomized 2204 symptomatic patients with paroxysmal or persistent atrial fibrillation (AF) 1:1 to percutaneous left atrial catheter ablation versus medical therapy Patients were > 65 years or < 65 years with > 1 risk factor for stroke Eligible for ablation and 2 rhythm or rate control drugs Primary endpoint - Composite of death, disabling stroke, serious bleeding, or cardiac arrest After a median follow up of 48.5 months, there was a nonsignificant 14% reduction with ablation as assessed by Intentionto-Treat (ITT).(HR 0.86; 95% CI ; p=0.30)

28 CABANA- Background Secondary endpoint - All cause mortality: A non-significant 15% reduction with ablation was observed (ITT).(HR 0.85; 95% CI ; p=0.377) 9% of the patients randomized to ablation never received the assigned treatment ablation and 27% of the medical therapy patients crossed over to ablation. Analyses by treatment received and per protocol showed significant benefits of ablation for both the primary endpoint and for mortality (33% reduction in primary endpoint and a 40% mortality risk reduction compared with drug therapy).

29 6 studies (2 randomized clinical trials and 4 observational studies)were entered in the meta-analysis. Despite significant heterogeneity, our data show that the prevalence of females amongst asymptomatic AF group was significantly less compared to the symptomatic AF group (RR, 0.57; 95% CI: ). No difference in age between asymptomatic and symptomatic AF patients (P= 0.72) was seen. No differences were found in all-cause death between patients with asymptomatic and symptomatic AF (RR, 1.38; 95% CI: ), nor in cardiovascular death (RR, 0.85; 95% CI: ) or stroke/thromboembolism (RR, % CI: ). International Journal of Cardiology 191 (2015)

30 Recommendations for patient involvement, education and selfmanagement

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