Dr. Eduardo Saad: Fibrilação atrial: O que há de mais moderno.
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O documento discute as mais recentes evidências sobre fibrilação atrial, incluindo: 1) a epidemiologia crescente da fibrilação atrial; 2) os novos anticoagulantes orais que evitam a necessidade de monitorização; 3) técnicas avançadas de ablação por cateter como o isolamento da veia pulmonar para tratamento da fibrilação atrial.
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Dr. Eduardo Saad: Fibrilação atrial: O que há de mais moderno.
- 1. Eduardo B. Saad, PhD, FHRS Coordenador do Serviço de Arritmias e Estimulação Cardíaca Centro de Fibrilação Atrial Hospital Pró-Cardíaco - Rio de Janeiro Hospital Samaritano - Rio de Janeiro Fibrilação Atrial em 2013: O Que Há de Mais Moderno? eduardobsaad@hotmail.com
- 2. Epidemiologia da Fibrilação Atrial: ATRIA Study 5,615,42 5,16 4,78 4,34 3,80 3,33 2,94 2,66 2,44 2,26 2,08 0 1 2 3 4 5 6 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2060 Year AdultswithAF,MM Projeção de Adultos com FA nos EUA: 1995 to 2050. Go A, et al. JAMA. 2001;285:2370-2375.
- 3. Impact of Atrial Fibrillation on the Risk of Death The Framingham Heart Study (N: 5209; 55 a 94 anos; : 40 years) A Fib M: 61.5% F: 57.6% O.R. = 1.5 - 1.9 No A Fib M: 30.0% F: 20.9% (55 a 74 anos)
- 4. Fibrilação Atrial Causa AVC
- 5. AVEs e Fibrilação Atrial Sources: Neurology, 1978; Stroke, 1985; European Heart Journal, 1987; Lancet, 1987; Fisher. Geriatrics. 1979;34:59 • 15 – 20% dos AVEs/ano relacionados a FA • Impacto funcional : Transient 11% Moderately Disabling 11% Non-Disabling 17% Severe Neurological Deficit 28% Unknown 2% Fatal 31%
- 8. Anticoagulantes: O que há de mais moderno?
- 9. AFASAKAFASAK 2727 811811 BAATAFBAATAF 1515 922922 CAFACAFA 1414 478478 SPAFSPAF 2323 508508 SPINAFSPINAF 2929 972972 Combined*Combined* 108108 36913691 No. ofNo. of EventsEvents Patient-Patient- yearsyears 100% 50% 0100% 50% 0 -50-50% -100%% -100% Warfarin BetterWarfarin Better Warfarin WorseWarfarin Worse Risk Reduction, %Risk Reduction, % *Total risk reduction for all 5*Total risk reduction for all 5 studies combined is 69%studies combined is 69% Eficárica da Warfarina na Prevenção de AVE
- 10. Benefício da Warfarina: Impacto da idade Singer D, Ann Int Med. 2009; 2009;151:297-305.
- 11. Dificuldades com o uso da Warfarina • Janela terapêutica estreita – Monitorização frequente • Risco de sangramento – Hemorragia intracraniana • Interações com drogas e alimentos • Relutância em prescrever em pacientes idosos – Risco de queda – Aderência duvidosa
- 12. X VIIaTF IX IXa Fibrinogenio Fibrina II Protrombina INICIAÇÃO PROPAGAÇÃO= Fase de geração de trombina FORMAÇÃO DO COÁGULO Fator Inativo Fator Ativo Transformação Catálise Legenda Xa Va Complexo Protrombinase Rivaroxabana, apixaban, edoxaban IIa Trombina Dabigatran Novos Anticoagulantes
- 13. Novos Anticoagulantes - Efeito dose dependente - Dispensa a monitorização com exames laboratoriais - Dose única ou duas tomadas diárias - Poucas interações medicamentosas ou com alimentos - Estudos randomizados controlados com grande número de pacientes - Cuidados!!! 1. Verificar a função renal 2. Não há como reverter o efeito rapidamente
- 14. New Engl J Med 2009; 361: 1139-51
- 15. 14.264 pts Rivaroxaban 20 mg Warfarina – INR 2-3 New Engl J Med 2011; 365:883-891
- 16. New Engl J Med 2011; 365:981-992
- 17. Manutenção do Ritmo Sinusal: O que há de mais moderno?
- 18. Manutenção do Ritmo Sinusal NEJM 2000; 342:913-20
- 19. Eficácia das Drogas Antiarrítmicas para Tratamento da FA Ritmo Sinusal (%) Sem droga 31 (15-56) Quinidina 41 (11-54) Disopiramida 49 (44-54) Propafenona 39 (30-46) Studies followed patients at least 6 months after cardioversion (adapted from Crijns) IaIa IcIc IIIIII ~50%-60%~50%-60% Ritmo SinusalRitmo Sinusal
- 20. 0 20 40 60 80 100 Non Drug Quinidine FlecainidePropafenone Sotalol Amiodarone Efficacy Discontinuation FA: Drogas Antiarrítmicas Studies followed patients at least 6 months after cardioversion (adapted from Crijns) 30%30% Taxa de SuspensãoTaxa de Suspensão
- 21. Torsade de Pointes Atrial Flutter 1:1 AV conduction EF 25% CAD
- 22. J Cardiovasc Electrophysiol 2008; 19: 1220-26 Modificação da molécula da Amiodarona: -Ausência de Iodo -Menos lipofílico – menor acúmulo tecidial -Meia vida – 1-2 dias (vs 30-55 dias – Amiodarona)
- 23. 67% 77% Recorrência - 96 dias vs 41 dias NEJM 2007; 357: 987-99 828 pt - Dronedarona 400 mg bid 409 pt - Placebo Sem diferenças em efeitos colaterais – pulmão, tireóide e fígado Aumento da incidência de disfunção renal (2,4% vs 0,2%)
- 24. NEJM 2009; 360: 668-78 4628 pt - Dronedarona 400 mg bid vs placebo > 70 anos Endpoint 1ário – Hospitalização ou morte 32% 39% Maior incidência de: - Prolongamento QT - Efeitos GIs - Disfunção renal (5%)
- 26. Recorrência de FA ou descontinuação da droga por intolerância ou ineficácia 504 pt J Cardiovasc Electrophysiol 2011; 21:597-605
- 28. Isolamento das Veias Pulmonares
- 29. Isolamento das Veias Pulmonares
- 30. Ablação de FA Wilber et al, JAMA, 2010 63% 17% All Recurrent AT/AFSymptomatic AT/AF 70% 19% Safety • Ablation Group (6.8%, n=103) – 1 pericarditis – 1 pulmonary edema –1 pericardial effusion (no tx needed) – 5 vascular complications – No Stroke/Embolism, Tamponade, Atrio-Esophageal fistula, PV stenosis, or Phrenic nerve paralysis • AAD group (17.9%, n=56) – 3 life-threatening ventricular arrhythmias – 7 disabling symptoms requiring drug withdrawal • One death in Ablation group, at 284 days, due to acute MI.
- 31. Circulation 2008; 118: 2498-2505 89% 23% - Média de 1,8 ± 0,8 ablações/pt - 2,5 ± 1 droga/pt - 75% com recorrência apesar do uso de droga classe III - Amiodarona - recorrência de FA em 66% - 63% crossover para ablação
- 32. Ablação por Cateter Resultados em Longo Prazo
- 33. Circ Arrhythm Electrophysiol 2011; 4:271-278 831 pts
- 34. Recorrências Tardias de FARecorrências Tardias de FA Ouyang F et al. Circulation 122:2368, 2010 Multiple Procedure Success Single Procedure Success Weerasooriya R et al. JACC 57:160, 2011 Singe Procedure Success Multiple Procedure Success
- 35. Mecanismos de Recorrência Após a Ablação
- 36. Mecanismos de Recorrência Após a Ablação
- 37. Mecanismos de Recorrência Após a Ablação
- 38. Estratégias para Reduzir Recorrências
- 39. Estratégias para Reduzir Recorrências
- 41. História Natural da FA Paroxística Terminação espontânea Permanente Não consegue reverter Persistente Ritmo sinusal com cardioversão elétrica ou química GatilhoGatilho IniciaçãoIniciação SubstratoSubstrato manutençãomanutenção
- 43. Isolamento da Parede Posterior
- 44. Isolamento da Parede Posterior
- 45. Heart Rhythm 2009; 6: 1403-1412 1404 pt com FA: Ablação guiada por ICE 12 operadores 4 centros Follow-up médio: 57 ± 17 meses 78% 67% 1a ablação Impact of Type of Atrial Fibrillation and Repeat Catheter Ablation on Long-Term Freedom from Atrial Fibrillation: Results from a Multicenter Study
- 50. Saad E at al. Circ Arrhythm Electrophysiol 2011; 4:615-
- 51. Resultados Complicações Cerebrovasculares: -AVE isquêmico - 0 - suspensão de DAA em 293 pt (89,6%) - suspensão do ACO em 298 pt (91,1%) -AVE hemorrágico -3 pt (0,9%) - durante ACO (2, 9 e 11 meses após ablação) - Sequelas motoras em todos os pt - 1 pt - cirurgia descompressiva
- 52. Monitores de Eventos Implantáveis
- 61. Prevenção de AVC: O que há de mais moderno?
- 62. Risco de sangramento maior no primeiro ano após o início da warfarina em idosos • 65 - 79 anos = 4.2% • ≥80 anos = 10.7% • Maior CHADS2 = maior risco de sangramentos • (quase 10x de score 0 a ≥4) Circulation 2007;115;2689 > 80 y < 80 y Uso de Anticoagulante Oral em Pacientes Idosos
- 63. Annals of Internal Medicine, 1999; 131(12): 927-934 0 20 40 60 80 <55<55 55-6455-64 65-7465-74 75-8475-84 >85>85 44%44% 58%58% 61%61% 57%57% 35%35% Age (years)Age (years) WarfarinUseinWarfarinUsein EligiblePatients(%)EligiblePatients(%) 55%55% OveralOveral l Usel Use Baixo uso da Warfarina
- 64. New Engl J Med 2009; 361: 1139-51
- 65. Considerações - Novos Anticoagulantes • Descontinuaç ão da droga - Dabigatrana - 21% - Rivaroxabana - 24% - Apixabana - 25% • Aumento do risco de sangramento - uso concomitante de antiplaquetários • Rely: > 75 anos - sangramento extracraniano > Warfarina
- 66. Auriculeta
- 67. 23 estudos - 2208 auriculetas examinadas em autópsia, ETE ou intra-operatório: 13% dos pt com trombo no AE AF valvar: 57% na auriculeta FA não-valvar: 90% na auriculeta Stroke 2007;38:624-30 Background
- 68. Oclusão Percutânea do AAE
- 71. PROTECT-AF Estudo randomizado O WATCHMAN pode substituir a Warfarina? Eficácia (endpoint): AVE Mortalidade CV Embolia sistêmica Segurança Estudo de não-inferioridade Follow-Up FA não valvar CHADs ≥ 1 Randomização (1:2) Warfarina Watchman Holmes, Reddy, et al. Lancet 2009; 374:534.
- 72. PROTECT - AF Holmes D; Lancet 2009
- 73. PROTECT - AF Holmes D; Lancet 2009
- 74. Indicações para Oclusão do AAE em 2013 • Pacientes com contraindicaç ão à anticoagulaç ão oral - sangramentos pré vios - percepç ão clínica de alto risco - aderência duvidosa - uso concomitante de antiplaquetários
- 75. Possíveis Indicações para Oclusão do AAE em 2013 • Desejo de evitar a anticoagulaç ão a longo prazo • Não-inferioridade • Concomitante a ablaç ão por cateter em pacientes de alto riso tromboembó lico
- 76. Tratamento da FA: Qual o Futuro?
- 77. Sala Híbrida
- 78. Tratamento de Arritmias - Robótica
- 79. Effects of Renal Sympathetic NervesEffects of Renal Sympathetic Nerves
- 80. Anatomic Location of Renal Sympathetic Nerves Schlaich, W. Presented at ESH 2010
- 81. Aplicações de Radiofrequência nas Artérias RenaisAplicações de Radiofrequência nas Artérias Renais
- 82. Artéria Renal DireitaArtéria Renal Direita
- 84. 14 pts 13 pts JACC 2012; 60:1163-1170
Notas del editor
- A stroke risk reduction of 69% attributable to warfarin was seen when the data from five studies were combined in the pooled analysis. All analyses represented for individual studies are done on an “intention-to-treat” basis. Note: Strokes represent all strokes regardless of suspected etiology. Transient ischemic attacks, systemic emboli and intracranial hemorrhages are not included. Control represents placebo in all studies except BAATAF where 46% of “control” patients received aspirin and 54% received no treatment. 20
- Background: Guidelines recommend warfarin use in patients with atrial fibrillation solely on the basis of risk for ischemic stroke without antithrombotic therapy. These guidelines rely on ischemic stroke rates observed in older trials and do not explicitly account for increased risk for hemorrhage. Objective: To quantify the net clinical benefit of warfarin therapy in a cohort of patients with atrial fibrillation. Design: Mixed retrospective and prospective cohort study of patients with atrial fibrillation between 1996 and 2003. Setting: An integrated health care delivery system. Patients: 13 559 adults with nonvalvular atrial fibrillation. Measurements: Warfarin exposure, patient characteristics, CHADS2 score (1 point for each of congestive heart failure, hypertension, age, and diabetes and 2 points for stroke), and outcome events were ascertained from health plan records and databases. Net clinical benefit was defined as the annual rate of ischemic strokes and systemic emboli prevented by warfarin minus intracranial hemorrhages attributable to warfarin, multiplied by an impact weight. The base-case impact weight was 1.5, reflecting the greater clinical impact of intracranial hemorrhage versus thromboembolism. Results: Patients accumulated more than 66 000 person-years of follow-up. The adjusted net clinical benefit of warfarin for the cohort overall was 0.68% per year (95% CI, 0.34% to 0.87%). Adjusted net clinical benefit was greatest for patients with a history of ischemic stroke (2.48% per year [CI, 0.75% to 4.22%]) and for those 85 years or older (2.34% per year [CI, 1.29% to 3.30%]). The net clinical benefit of warfarin increased from essentially zero in CHADS2 stroke risk categories 0 and 1 to 2.22% per year (CI, 0.58% to 3.75%) in CHADS2 categories 4 to 6. The patterns of results were preserved when weighting factors for intracranial hemorrhage of 1.0 and 2.0 were used. Limitations: Residual confounding is a possibility. Some outcome events were probably missed by the screening algorithm or when medical records were unavailable. Conclusion: Expected net clinical benefit of warfarin therapy is highest among patients with the highest untreated risk for stroke, which includes the oldest age category. Risk assessment that incorporates both risk for thromboembolism and risk for intracranial hemorrhage provides a more quantitatively informed basis for the decision on antithrombotic therapy in patients with atrial fibrillation.
- Reference Kubitza D and Haas S. Expert Opin Investig Drugs 2006;15:843–855
- And in pts with chronic atrial fibrillation, As you can see, the overall efficacy of these medications in terms of maintaining sinus rhythm at 6 months range between 40-60%. I tell all my patients who I start on AAD that AF is going to come back. (Define AAD failure).
- Not only that , but the potential negative side effects result in a relatively high discontinuation rate. If you look at this for example you see that amiodarone has a relatively high discontinuation rate, almost 20% at 6 months stop taking it, mostly because of its extracardiac side effects. It can affect the thyroid, the liver, the lung, the skin , the eyes and the CNS. This is why we tend to avoid it in young patients unless you want them to end up as blue cretins, wheeezing and limping but in NSR.
- And some of the side effects are actually serioutransform AF into AFs and fatal. Such as what you see with the use of class 3 AAD such as sotalol or dofetilide. Similarly, patients with structural heart disease cannot be treated with class I antiarrhythmic such as flecainide or propafenone because of the risk of proarrhtyhmia such as VF. Even in patients with no structural heart disease, class IC drug can transform atrial fibrillation into AFl which is slow enough to conduct 1:1 to the V and result into a WCT that resembles VT and can actually degenerate into VF.
- This has changed significantly our understanding of atrial fibrillation. Indeed the natural history of AF is to procced from intermittent self terminating episodes episodes of AF to a more persistent form requiring frequent DC cardioversions over time to finally telling the patient that there is not much that we can do about it and that they have to spend the rest of their lives in AF. And we know why this happens And there is a good reason for this to happen. With more atrial fibrillation, there is a change in the electrophysiologic environment of the atria, or atrial remodeling which occur which favors reentry. So, our understanding of atrial fibrillation has changed. We havetriggers,which are rapid firing recorded within the PV that propagagte tto the atrium. If the electrophysiologic environment in the atrium is suitable for sustaining AF, what is commonly known as F conduction, the AF persists, if not then AF terminates or never starts. This is what happens initially we have paroxysms of AF: it strats/ stops because the substrate is not ready for AF yet. But with more and more paroxysms and with some modulating factors, Athere are changes in the EP properties of the atria which favor reentry and tend to be more inviting for sustaining AF. What triggers PV firing? We do not know: is it automaticity, EAD with TDP like phenomenon in the atria, is it only one impulse with circual conduction that is rapid or leakage from the rapid firing of the SM cells in the wall of the veins: we do not know yet. that start off AF. and a or which start of AF and it is up to the atrial substarte to mintain AF or not. a substarate. initiators, perpetuators and underlying substarte. What is responsible for the firing within the PV? For some reason some people have a substrate for triggers which cause the rapid firing seen in the PV ’s. Initially this is usually paroxismal in nature. The atrial substarte is not mature for AF to settle in yet.It is like trying to start a car in a cold wheather you try many times but it doesn’t start. With time atrial remodeling occurs and with the help of other factors such as …, the atrial substrate becomes more inviting for permanent atrial fibrillation. And there might be some erpetuators in the meantime such as intermittent ongoing PV activity which tends to cause ongoing AF.
- In this presentation, will show the 1050 pt-yr data