A Critical Juncture in Management

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A Critical Juncture in Management
Arrythmia

• Moneera Haque
• Research Elective
• July 24, 2006

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GeorgeI didnt get the page
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(No Transcript)
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Background

• Atrial Fibrillation (AF) is a common and growing
  problem
• Affects 2.2 million persons in the US
• Recent data suggests that the number of
  hospitalizations with AF as the first listed
  diagnosis increased 34 from 1996 to 2001
• At age 40, lifetime risk for AF is 26 for men
  and 23 for women.

Khairallah F et al., Epidemiology and
determinants of outcome of admissions for atrial
fibrillation in the United States from 1996 to
2001. Am J Cardiol 200494500-4.
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Background Contd
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Current Approaches

• Current Management
• Ventricular rate control
• Rhythm control
• Trials
• RACE Rate Control vs. Electrical Cardioversion
  for Persistent Atrial Fibrillation
• AFFIRM Atrial Fibrillation Followup
  Investigation of Rhythm Management

Van Gelder IC, Hagens VE, Bosker HA, et al. A
comparison of rate control and rhythm control in
patients with recurrent persistent atrial
fibrillation. N Engl J Med 20023471834-40.
Wyse DG, Waldo AL, DiMarco JP, et al. The atrial
fibrillation follow-up investigation of rhythm
management (AFFIRM Investigators). A comparison
of rate control and rhythm with atrial
fibrillation. N Engl J Med 20023471825-33.
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Elusive Panacea

• Despite the large number of patients treated with
  therapies for AF, the best pharmacologic approach
  remains unknown.
• Beta-blockers, calcium channel blockers, and
  digoxin have been compared in small studies, but
  no large trial has determined the optimal
  pharmacologic method to control AF.
• Most patients have an adequate response to the
  available drug classes, although frequent
  medication changes may be necessary and
  combinations may be needed.

Kaufman ES, Zimmermann PA, Wang T, et al. AFFIRM
Investigators The risk of proarrhythmic events in
Atrial Fibrillation Follow-up Investigation of
Rhythm Management (AFFIRM) study. J Am Coll
Cardiol 2004441276-82.
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Give me a reason

• Reasons for restoration and maintenance of sinus
  rhythm include
• relief of symptoms
• prevention of embolism
• avoidance of cardiomyopathy
• Fewer than 50 of patients on an antiarrhythmic
  regimen remained in sinus rhythm at the end of 1
  year.
• This has led to increasing interest in
  non-pharmacologic treatments.

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Ablate me baby

• 1959- Multiple wavelet" hypothesis described by
  Moe and Abildskov.
• 1988- The discovery by Haissaguerre et al. showed
  that focal ablation could eliminate paroxysmal AF
  represented a major therapeutic advance.
• Today, ablation of AF foci is being widely used
  as one of the non-pharmacologic therapies for
  eradicating AF.

Moe GK, Abildskov JA. Atrial fibrillation as a
self-sustaining arrhythmia independent of focal
discharge. Am Heart J 19595859 70.
Haissaguerre M, Jais P, Shah DC, et al.
Spontaneous initiation of atrial fibrillation by
ectopic beats originating in the pulmonary veins.
N Engl J Med 1998339659-66.
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Catheter Ablation
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When Oh When
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Rationale for Investigation

• The Trifecta
• The Dilemma
• Antiarrythmic Drugs vs Ablation?
• A research approach to advance our understanding
  of therapeutic options for the management of
  atrial fibrillation

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Methods

• Literature Search
• Creating survey questions
• Validating questions
• Sent surveys out

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To be continued

• The results of this study should provide
  information concerning practice management by
  cardiologists of widely applicable treatment
  strategies of atrial fibrillation.

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July 1st
July 24th