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Role of Pacemakers and ICDs in AF Diagnosis and Management

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Role of Pacemakers and ICDs in AF Diagnosis and Management Ian Wright Principal Cardiac Physiologist Imperial College Healthcare NHS Trust Cardiac Rhythm Management ... – PowerPoint PPT presentation

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Title: Role of Pacemakers and ICDs in AF Diagnosis and Management


1
Role of Pacemakers and ICDs in AF Diagnosis and
Management
  • Ian Wright
  • Principal Cardiac Physiologist
  • Imperial College Healthcare NHS Trust

2
Cardiac Rhythm Management
3
And Disease Management
  • Integrate CRM device data into into treatment
    pathways for chronic conditions
  • Ventricular arrhythmias
  • Heart failure
  • Syncope
  • Atrial fibrillation

4
AF in pacemaker and ICD patients
  • AF common in the device population
  • Device population high risk for stroke
  • Modern implantable devices are capable of
    accurately detecting and recording AT/AF events

5
Challenges and Opportunities
  • Identification
  • Most AF episodes are asymptomatic but still carry
    all the risks of the arrhythmia.
  • AF often detected first at device follow-up

6
National clinical guideline for management in
primary and secondary care 2006
  • Stroke risk algorithm should be used and appr.
    thromboprophylaxis given
  • Anti-thrombotic therapy should be initiated with
    minimal delay

7
Remote Monitoring
  • Biotronik Home Monitoring
  • Medtronic Carelink
  • St Jude Merlin.net
  • Boston Scientific Latitude
  • Allows clinicians to respond more proactively to
    changes in patient or device status and more
    appropriately triage patient care.

8
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10
  • Management treatment decisions
  • How to react to the device data
  • Change of approach to device follow-up
  • Education of follow-up staff
  • Integration with other services

11
HRS/EHRA Expert Consensus on the Monitoring of
Cardiovascular Implantable Electronic Devices 2008
  • Pacemakers ICDs CRTs
  • North America 64,074 234,780 148,092
  • Europe 683,472 87,747 61,010
  • 1,279,175 implanted devices
  • Number of Follow-up encounters/year Pacemaker
    ICD
  • North America 1,610,000 2,065,000
  • Europe 1,680,000 500,000
  • Total Numbers 3,290,000 2,565,000
  • 5,855,000 follow-up encounters
  • Based on one encounter/year for Pacing in North
    America and Western Europe. 2.5 encounters/year
    for ICDs in Western Europe, and 3.5 in North
    America. Pacemaker Therapies are Pacemakers with
    without CRT and ICD Therapies are ICDs with
    without CRT.

12
Large device centre
  • 3-4000 device patients
  • 1000 CRT devices
  • 10,000 follow-ups

13
AF common in device population 1. Cardiac Causes
of AF
  • Common cardiac causes
  • ischaemic heart disease
  • rheumatic heart disease
  • hypertension
  • sick sinus syndrome
  • pre-excitation syndromes
  • (eg WolffParkinsonWhite).
  • Less common cardiac causes
  • cardiomyopathy or heart muscle disease
  • pericardial disease (including effusion and
  • constrictive pericarditis)
  • atrial septal defect
  • atrial myxoma.

14
  • AF is a confounding factor in 20-26 of all HF
    patients and makes treatment even more
    challenging
  • Benjamin E.J., Levy D, et al. Independent risk
    factors for atrial fibrillation in a
    population-based cohort The Framingham Heart
    Study JAMA 1994 271(11)840-844.

15
AF in the device population2. Age
  • The prevalence of AF roughly doubles with each
    advancing decade of age, from 0.5 at age 5059
    years to almost 9 at age 8089 years.
  • Kannel WB, Wolf PA, Benjamin EJ et al.
    Prevalence, incidence, prognosis, and
    predisposing conditions for atrial fibrillation
    population-based estimates. American Journal of
    Cardiology. 199882(8A)2N9N.

16
Stroke And AF
  • AF is associated with approximately 10-15 of all
    strokes

1 Stafford R.S., Robson D.C., et al. Rate
control and sinus rhythm maintenance in atrial
fibrillation National trends in medication use.
Arch Intern Med 1998 158 2144-2148.
17
Device popn Annual Event Rates
Evidence Review Implanted cardiac devices with
remote monitoring facilities NHS Centre for
Evidence-based Purchasing, April 09
18
  • Evidence Review Implanted cardiac devices with
    remote monitoring facilities
  • NHS Centre for Evidence-based Purchasing, April
    09

19
Large Device Centre
  • 3,500 patients
  • 4.5 158 strokes/year

20
Device population high risk for stroke
21
National clinical guideline
Note that risk factors are not mutually
exclusive, and are additive to each other in
producing a composite risk.
22
Note that risk factors are not mutually
exclusive, and are additive to each other in
producing a composite risk.
23
Risk what does it mean?
  • High A 6-12 in 100 chance (sometimes higher) of
    having a stroke in the next year without
    treatment.
  • Moderate About a 3-5 in 100 chance of having a
    stroke in the next year.
  • Low 1-2 in 100 chance or less of having a
    stroke in the next year.

24
Thrombo-prophylaxis
  • Warfarin reduces the risk of stroke by nearly
    two-thirds.
  • In other words, warfarin treatment can prevent
    about 6 in 10 strokes that would have occurred in
    people with AF.
  • For people with AF who are at high risk of
    stroke, about 80-90 strokes will be prevented
    each year for every thousand people treated with
    warfarin.

25
Evidence Review Implanted cardiac devices with
remote monitoring facilities NHS Centre for
Evidence-based Purchasing, April 09
26
CRT patients Large Centre
  • 1000 device patients with heart failure
  • 20-25 incidence of AF
  • 20 200 experience AF
  • 80-90 strokes will be prevented in high risk
    group each year for every thousand people treated
    with warfarin
  • 16-18 strokes prevented by appropriate warfarin
    therapy
  • Acute mortality 19 4 preventable deaths
  • Cost pp 3938.72 63-71k saved (1 year)

27
  • Mr Hill Age 78 Bivent PPM
  • Heart Failure
  • Now in AF (prev SR). Asymptomatic. Device
    mode-switched appropriately.
  • RV Threshold OK. Battery OK.
  • Next check 12M

28
Challenges
  • How much atrial fibrillation burden needs to be
    present to invoke the guidelines?

29
What about
  • A single long episode with no further episodes?
  • More frequent episodes that only last a few
    seconds or minutes?
  • Should burden be considered as another continuous
    risk factor on the list (like age) or as a
    threshold that must be crossed before invoking
    other risk factors?

30
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33
  • Device-detected atrial tachycardia (AT)/atrial
    fibrillation (AF) burden can be used to stratify
    the risk of thromboembolic events (TEs).
  • The precise AT/AF burden threshold that warrants
    additional medical intervention needs to be
    determined in further studies.

34
Trials and Registries
  • RATE
  • ASSERT
  • TRENDS
  • IMPACT

35
Registry of Atrial Tachycardia and Atrial
Fibrillation Episodes in the cardiac rhythm
management device population
  • What burden of AF episodes in the device
    population is predictive of important clinical
    outcomes?
  • Demographic and initial clinical data will be
    correlated with atrial fibrillation burden and
    with other outcome measures relating to therapies
    and adverse events.
  • Waldo et al, American Heart Journal, June 2009

36
Predicted rates
  • Sample size Results
  • Total estimated sample size 5,000
  • Observation period 2 y
  • Predicted number of patients
  • who will develop AF during
  • the observation period 2,045
  • Expected number of clinical events 949
  • Large Centre 3500 patients 1435 develop AF
  • Expected number of clinical events 665 events

37
ASymptomatic AF and Stroke Evaluation in
Pacemaker Patients and the AF Reduction Atrial
Pacing Trial
  • Will evaluate whether the detection of atrial
    high-rate episodes with pacemaker telemetry can
    predict an increased risk of stroke

38
TRENDS
  • A Prospective Study of the Clinical Significance
    of Atrial Arrhythmias Detected by Implanted
    Device Diagnostics
  • 21 of patients were on warfarin and 62 were on
    aspirin
  • Results suggest that device-detected AT/AF burden
    5.5 h on any day during the preceding 30 days
    doubles the risk for thromboembolic events
    independent of known risk factors and
    antithrombotic therapy antithrombotic therapy.

Presentation at ACC Annual Scientific Session 2008
39
Home Monitoring
  • The IMPACT of BIOTRONIK Home Monitoring Guided
    Anticoagulation on Stroke Risk in Patients With
    Implanted ICD and CRT-D Devices study

40
Summary
  • AF common in the device population
  • Device population high risk for stroke
  • AF often detected first at device follow-up
  • Potential to act more rapidly than in any other
    group to reduce impact of AF
  • Requires rethink of the aims, organisation and
    administration of CRM clinics to maximise
    potential of new technology

41
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