Κολπική µαρµαρυγή: Ρύθµιση ρυθµού ή συχνότητας Βασίλειος Π. Βασιλικός F.A.C.C., F.E.S.C. Αναπληρωτής Καθηγητής Καρδιολογίας Α.Π.Θ.
Κολπική µαρµαρυγή Ανοµοιογενής πληθυσµός Διαφορετικός κίνδυνος Υποκείµενη αιτία
Camm et al, Eur Heart J, 2010
AF mechanisms Paroxysmal AF Trigger Persistent AF Substrate No Structural Heart Disease PV triggers Structural Heart Disease Multiple Wavelets, Nests, Rotors
Pharmacological Actions in Paroxysmal AF Pathologic Automaticity Phase 4 Depression Action Potential in Persistent AF Refractory - blocked Reentry excitable ERP prolongation Vmax, Conduction velocity
Επιλογές
Επιλογές Ανάταξη επεισοδίου
Επιλογές Ανάταξη επεισοδίου Διατήρηση ρυθµού
Επιλογές Ανάταξη επεισοδίου Διατήρηση ρυθµού Επιλογή ελέγχου της συχνότητας
AF Treatment Options Dronedarone
Επιλογές Ανάταξη επεισοδίου Διατήρηση ρυθµού Επιλογή ελέγχου της συχνότητας
Why to convert rapidly to sinus
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
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
Longer AF duration was associated to higher risk of stroke in the AFFIRM study Covariate p HR 95% CI Age at enrollment 0.02 1.02 1.00-1.04 Duration of qualifying episode 2 days Female sex 0.003 1.66 1.19-2.31 0.02 1.61 1.08-2.40 Diabetes mellitus 0.01 1.62 1.11-2.35 Stroke or transient ischemic attack 0.006 1.78 1.19-2.68 Atrial fibrillation 0.01 1.62 1.11-2.30 Warfarin use 0.001 0.31 0.21-0.46 Sherman DG et al. Arch Intern Med. 2005;165:1185-1191
Atrial Remodeling Electrical remodeling Structural remodeling
Electrical remodelling. Atrial fibrillation shortens effective refractory period (Animal model) Wijffels et al. Circulation. 1995;92:1954-1968 Allessie et al. Cardiov Res 2002;54:230-46
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 1 2 3 4 5 6 7 30 Time to full recovery of atrial systolic function (days) Manning et al. J Am Coll Cardiol. 1994;23:1535-40
Who needs cardioversion?
Who needs cardioversion? Hemodynamically unstable patient
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
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
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.
Drugs vs D/C: simpler but less efficacious
Drugs vs D/C: simpler but less efficacious Risk: drug toxicity
Drugs vs D/C: simpler but less efficacious Risk: drug toxicity More efficacious within 7 days of episode
Drugs vs D/C: simpler but less efficacious Risk: drug toxicity More efficacious within 7 days of episode NB: spontaneous cardioversion within 24-48 hours
Camm et al, Eur Heart J 2010
I I IIa IIb I IIa Camm et al, Eur Heart J 2010
Επιλογές - χρονιότητα Ανάταξη επεισοδίου Διατήρηση ρυθµού Επιλογή ελέγχου της συχνότητας
Διατήρηση ΦΚ ρυθµού - Φάρµακα
Διατήρηση ΦΚ ρυθµού - Φάρµακα Ποσοστό διατήρησης 30-50%
Διατήρηση ΦΚ ρυθµού - Φάρµακα Ποσοστό διατήρησης 30-50% Αµιωδαρόνη, Προπαφαινόνη, Φλεκαϊνίδη, Σοταλόλη
Διατήρηση ΦΚ ρυθµού - Φάρµακα Ποσοστό διατήρησης 30-50% Αµιωδαρόνη, Προπαφαινόνη, Φλεκαϊνίδη, Σοταλόλη ΠΑΡΕΝΕΡΓΕΙΕΣ!
Sinus rhythm strategy: Who are appropriate candidates?
Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF
Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause
Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode
Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age
Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control
Sinus rhythm strategy: Who are appropriate candidates? Highly symptomatic with AF Reversible cause First episode Young age Symptomatic despite rate control Rate-related cardiomyopathy
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
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
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
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;347:1825-33
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;347:1825-33
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;358:2667 77
AF - CHF Trial Roy et al. NEJM 2008;358:2667 77
Roy et al. NEJM 2008;358:2667 77
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 85 70 AF- CHF Rate Control N=175 10% 21% Rhythm Control N=182
AFFIRM: Independent predictors of survival The risks of AADs counterbalance the benefits of sinus rhythm Corley et al. Circulation 2004;109:1509-13
Efficacy of AADs AFFIRM 35 63 EURIDIS and ADONIS STAF 9 25 36 38 Στήλη1 Rhythm control Rate control RACE 10 39 AF-CHF 42 30 0 25 50 75 100 % maintenance of SR
Amiodarone: the most effective AA agent Roy et al. NEJM 2000;342:913-20
Dronaderone Hohnloser et al, ATHENA trial, N Eng J Med 2009
Dronaderone Hohnloser et al, ATHENA trial, N Eng J Med 2009
Rx and exercise Farshi et al, JACC 1999
Camm et al, Eur Heart J, 2010
CV Hospitalizations
Total mortality
ICU hospital stays or Death
Time to first ICUH
Camm et al, Eur Heart J, 2010
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;54:1089 95
Camm et al, Eur Heart J, 2010
Mortality outcomes in AF Freemantle et al, AHA, November 2009
Camm et al, Eur Heart J, 2010
RACE
RACE
EURIDIS, ADONIS trial, NEJM 2007
HR decrease Davy et al, ERATO trial, Am Heart J 2008