Κολπική µαρµαρυγή: Ρύθµιση ρυθµού ή συχνότητας. Βασίλειος Π. Βασιλικός F.A.C.C., F.E.S.C. Αναπληρωτής Καθηγητής Καρδιολογίας Α.Π.Θ.

Transcript

1 Κολπική µαρµαρυγή: Ρύθµιση ρυθµού ή συχνότητας Βασίλειος Π. Βασιλικός F.A.C.C., F.E.S.C. Αναπληρωτής Καθηγητής Καρδιολογίας Α.Π.Θ.

2 Κολπική µαρµαρυγή Ανοµοιογενής πληθυσµός Διαφορετικός κίνδυνος Υποκείµενη αιτία

3 Camm et al, Eur Heart J, 2010

4 AF mechanisms Paroxysmal AF Trigger Persistent AF Substrate No Structural Heart Disease PV triggers Structural Heart Disease Multiple Wavelets, Nests, Rotors

5 Pharmacological Actions in Paroxysmal AF Pathologic Automaticity Phase 4 Depression Action Potential in Persistent AF Refractory - blocked Reentry excitable ERP prolongation Vmax, Conduction velocity

6 Επιλογές

7 Επιλογές Ανάταξη επεισοδίου

8 Επιλογές Ανάταξη επεισοδίου Διατήρηση ρυθµού

9 Επιλογές Ανάταξη επεισοδίου Διατήρηση ρυθµού Επιλογή ελέγχου της συχνότητας

10 AF Treatment Options Dronedarone

11 Επιλογές Ανάταξη επεισοδίου Διατήρηση ρυθµού Επιλογή ελέγχου της συχνότητας

12 Why to convert rapidly to sinus

13 Why to convert rapidly to sinus Because But Sinus rhythm is associated to fewer cardiovascular complications and lower mortality Duration of AF episodes can condition a worse prognosis AF begets AF Sinus rhythm improves symptoms and quality of life Sinus rhythm do not avoid anticoagulation (warfarin) Current antiarrhythmic drugs to convert / maintain

14 Prompt cardioversion can reduce the total burden of AF and the number of recurrences requiring cardioversion Total duration of atrial fibrillation (AF} for each patient during the first and second 3-month periods after an atrial defibrillator was implanted. Circles represent the mean duration (±SD) of AF in all of the patients. Triangles and squares represent the mean (± I SD) and individual data for patients with persistent and paroxysmal atrial fibrillation, respectively. Tse et al. Card Electrophysiol Rev. 2003;7:359-65

15 Longer AF duration was associated to higher risk of stroke in the AFFIRM study Covariate p HR 95% CI Age at enrollment Duration of qualifying episode 2 days Female sex Diabetes mellitus Stroke or transient ischemic attack Atrial fibrillation Warfarin use Sherman DG et al. Arch Intern Med. 2005;165:

16 Atrial Remodeling Electrical remodeling Structural remodeling

17 Electrical remodelling. Atrial fibrillation shortens effective refractory period (Animal model) Wijffels et al. Circulation. 1995;92: Allessie et al. Cardiov Res 2002;54:230-46

18 Contractile remodelling. Recovery of atrial contractility after conversion to sinus rhythm depends on AF duration AF > 6 weeks duration AF >2 to 6 weeks duration AF 2 weeks duration Time to full recovery of atrial systolic function (days) Manning et al. J Am Coll Cardiol. 1994;23:

19 Who needs cardioversion?

20 Who needs cardioversion? Hemodynamically unstable patient

21 Who needs cardioversion? Hemodynamically unstable patient Those in whom a long-term rhythm strategy has been chosen over a rate control strategy will need to be cardioverted

22 Who needs cardioversion? Hemodynamically unstable patient Those in whom a long-term rhythm strategy has been chosen over a rate control strategy will need to be cardioverted Those with new onset AF

23 Who needs cardioversion? Hemodynamically unstable patient Those in whom a long-term rhythm strategy has been chosen over a rate control strategy will need to be cardioverted Those with new onset AF Those who have failed a rate control strategy.

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25 Drugs vs D/C: simpler but less efficacious

26 Drugs vs D/C: simpler but less efficacious Risk: drug toxicity

27 Drugs vs D/C: simpler but less efficacious Risk: drug toxicity More efficacious within 7 days of episode

28 Drugs vs D/C: simpler but less efficacious Risk: drug toxicity More efficacious within 7 days of episode NB: spontaneous cardioversion within hours

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31 Camm et al, Eur Heart J 2010

32 I I IIa IIb I IIa Camm et al, Eur Heart J 2010

33 Επιλογές - χρονιότητα Ανάταξη επεισοδίου Διατήρηση ρυθµού Επιλογή ελέγχου της συχνότητας

34 Διατήρηση ΦΚ ρυθµού - Φάρµακα

35 Διατήρηση ΦΚ ρυθµού - Φάρµακα Ποσοστό διατήρησης 30-50%

36 Διατήρηση ΦΚ ρυθµού - Φάρµακα Ποσοστό διατήρησης 30-50% Αµιωδαρόνη, Προπαφαινόνη, Φλεκαϊνίδη, Σοταλόλη

37 Διατήρηση ΦΚ ρυθµού - Φάρµακα Ποσοστό διατήρησης 30-50% Αµιωδαρόνη, Προπαφαινόνη, Φλεκαϊνίδη, Σοταλόλη ΠΑΡΕΝΕΡΓΕΙΕΣ!

38 Sinus rhythm strategy: Who are appropriate candidates?

39 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF

40 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause

41 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode

42 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age

43 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control

44 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control Rate-related cardiomyopathy

45 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control Rate-related cardiomyopathy LV dysfunction/ symptomatic AF

46 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control Rate-related cardiomyopathy LV dysfunction/ symptomatic AF Diastolic dysfunction with symptoms

47 Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control Rate-related cardiomyopathy LV dysfunction/ symptomatic AF Diastolic dysfunction with symptoms

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49 AFFIRM Trial: Rhythm vs Rate Control 4060 patients (mean age 69.7±9.0 y) with atrial fibrillation and risk of stroke or death Rhythm Control Amiodarone 63% Sotalol 41% Propafenone 14% Procainamide 8% Quinidine 7% Flecainide 8% Disopyramide 4% Moricizine 2% Dofetilide 0,6% Rate Control Digoxin 70% Beta-blocker 68% Diltiazem 46% Verapamil 17% Wyse et al. NEJM 2002;347:

50 AFFIRM Trial: Rhythm vs Rate Control Cumulative mortality from any cause in the rhythm-control group and the rate-control group Wyse et al. NEJM 2002;347:

51 AF - CHF Trial 1376 pts (123 sites, 10 countries) with LVEF 35% and recent AF Rhythm Control: antiarrhythmic drugs (amiodarone 82%), cardioversions intended to maintain sinus rhythm Rate Control: b-blockers, digoxin to control ventricular rate ACE inhibition, ß-blockers, and warfarin (> 90%) Mean follow-up: 37 months Roy et al. NEJM 2008;358:

52 AF - CHF Trial Roy et al. NEJM 2008;358:

53 Roy et al. NEJM 2008;358:

54 High crossover rate from rhythm to rate control AFFIR M Rate Control N=2027 Cross-over 14,9% 37,5% Rhythm Control N=2033 Rate OAC AF- CHF Rate Control N=175 10% 21% Rhythm Control N=182

55 AFFIRM: Independent predictors of survival The risks of AADs counterbalance the benefits of sinus rhythm Corley et al. Circulation 2004;109:

56 Efficacy of AADs AFFIRM EURIDIS and ADONIS STAF Στήλη1 Rhythm control Rate control RACE AF-CHF % maintenance of SR

57 Amiodarone: the most effective AA agent Roy et al. NEJM 2000;342:913-20

58 Dronaderone Hohnloser et al, ATHENA trial, N Eng J Med 2009

59 Dronaderone Hohnloser et al, ATHENA trial, N Eng J Med 2009

60 Rx and exercise Farshi et al, JACC 1999

61 Camm et al, Eur Heart J, 2010

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63 CV Hospitalizations

64 Total mortality

65 ICU hospital stays or Death

66 Time to first ICUH

67 Camm et al, Eur Heart J, 2010

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69 Amiodarone vs Dronedarone recurrent atrial fibrillation Indirect meta-analysis and direct randomized data suggest that amiodarone is more effective than dronedarone in maintaining SR all-cause death adverse events Piccini et al. JACC 2009;54:

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74 Camm et al, Eur Heart J, 2010

75 Mortality outcomes in AF Freemantle et al, AHA, November 2009

76 Camm et al, Eur Heart J, 2010

77 RACE

78 RACE

79 EURIDIS, ADONIS trial, NEJM 2007

80 HR decrease Davy et al, ERATO trial, Am Heart J 2008