Atrial Fibrillation Management Quiz

Treatment of Atrial Fibrillation

• Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the U.S.
• Estimated 50 million people worldwide are affected.
• Annual US healthcare costs are $28.4 billion.
• AF incidence and prevalence increase in some populations.
• AF is associated with poor outcomes and a decreased quality of life.
• Increased rates of death, stroke, and thromboembolic events are associated with AF.
• Men experience a higher incidence of AF than other groups.
• Caucasians have a higher incidence of AF than other groups.
• AF prevalence data is tracked by social demographic indexes, including income per capita, mean educational achievement (≥15 years), and total fertility rate (<25 years).
• Cardiac dysrhythmia hospitalization rates for adult Medicare beneficiaries (ages 65+) vary by county in the U.S.

Recent Guidelines and Statements

• 2023 ACC/AHA/ACCP/HRS Guidelines for the Diagnosis and Management of Atrial Fibrillation
• 2022 CHEST Guideline: Perioperative Management of Antithrombotic Therapy
• 2020 ACC Expert Consensus Decision Pathway for Anticoagulation and Antiplatelet Therapy in Patients with Atrial Fibrillation or VTE Undergoing PCI or with ASCVD
• 2019 ACC/AHA/HRS Focused Update of the 2014 Guideline for the Management of Patients with Atrial Fibrillation
• 2014 ACC/AHA/HRS Guideline for the Management of Patients with Atrial Fibrillation

Learning Objectives

• Recognize common mechanisms and agents associated with drug-induced atrial fibrillation (AF).
• State the diagnostic study that identifies AF.
• Design appropriate pharmacological treatment regimens for acute and chronic management of AF (for rate, anticoagulation, rhythm, including device-related) from a patient case.
• Relate appropriate route of drug administration based on hemodynamic state of the patient.
• Distinguish drugs that can and cannot be given to a patient with pre-excitation.
• Distinguish appropriate and inappropriate agents for pharmacological conversion of AF.
• Describe appropriate patient safety considerations for pill-in-the-pocket strategy.
• State rate control goals.
• Calculate CHA2DS2-VASc and HAS-BLED scores from a patient case.
• Relate modifiable risk factors for bleeding and strategies to minimize bleeding risk.
• Outline appropriate use of bridging therapy in AF patients.
• Contrast valvular AF (EHRA Type 1) with non-valvular AF (EHRA Type 2).
• Recognize lifestyle and risk factor modifications identified for AF patients by the AHA.

Atrial Fibrillation (AF)

• AF is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation.
• Atrial contraction is irregular and chaotic.
• Coordination between the atria and ventricles is lost.
• Diagnosis involves ECG demonstrating >30 seconds of heart rhythm with no discernible repeating P waves and irregular RR intervals.

Many Drugs Contributing to AF Development

• Adrenergic stimulation
• Vagal stimulation
• Direct cardiotoxicity
• Changing atrial conduction, refractoriness, or automaticity
• Coronary vasoconstriction/ischemia
• Electrolyte disturbances

Agents Implicated in Drug-Induced AF

• Albuterol
• Alcohol
• Alendronate
• Caffeine
• Dobutamine
• Fluoxetine
• Ipratropium
• Methylprednisolone
• Mitoxantrone
• Milrinone
• Paclitaxel
• Theophylline
• Others

First Detection of AF

• Irregular pulse
• Symptoms (racing heart, fluttering, palpitations, shortness of breath, lightheadedness)
• Ischemic stroke or TIA.

Patient Interview

• Symptomatology (onset, frequency, duration, precipitating and relieving factors)
• Previous response to medications
• Underlying heart disease or other reversible conditions
• Home medications

Clinical Evaluation of AF

• Echocardiography (transthoracic or transesophageal)
• Valvular heart disease
• Left Atrial (LA) and Right Atrial (RA) size and function
• Left ventricular (LV) size and function
• LV hypertrophy
• Pericardial disease
• Laboratory Tests (TSH, T4, serum creatinine, electrolytes, liver function tests, pregnancy tests)

OLD Classification of AF

• Paroxysmal (typically <48 hours)
• Persistent (duration > 7 days, requires cardioversion)
• Long-standing (persistent AF for >1 year)
• Permanent (accepted, no attempts to restore normal sinus rhythm)

New AF Stages

• At Risk
• Pre-AF
• Paroxysmal AF (3A)
• Persistent AF (3B)
• Long-Standing Persistent AF (3C)
• Successful AF ablation (3D)
• Permanent AF (4)

Staging: AF 1 and AF 2

• AF1 (Modifiable Risk Factors): Obesity, lack of fitness, hypertension, sleep apnea, alcohol use, and diabetes
• AF1 (Non-Modifiable Risk Factors): Genetics, male sex, age
• AF2 (Structural Findings): Atrial enlargement, valve disease, hypertrophic cardiomyopathy, and left ventricular hypertrophy
• AF2 (Electrical Findings): Frequent atrial ectopy, short bursts of atrial tachycardia, atrial flutter, and prolonged PR interval.

Therapeutic Considerations in AF

• Acute treatment (addressing immediate issues)
• Prevention of progression
• Chronic treatment (long-term management)

Acute Management of AF

• Is the patient hemodynamically stable? -Rhythm Control (in selected patients) -Anticoagulation (required in most patients) -Rate Control (always addressed)
• Acute rhythm control
  • Possible Reasons for unstable hemodynamic status
    • Loss of coordinated contraction
    • High ventricular rate
    • Irregular ventricular response
    • Decrease in myocardial blood flow
  • Signs and symptoms of instability: hypotension, altered mental status, signs of shock, ischemic chest discomfort, pulmonary edema (acute HF), and decreased urinary output.
• Acute rate control: options (IV/PO digoxin, amiodarone, beta blockers, and other options).

Acute Rate Control

• Consider likelihood of therapeutic success with PO administration:
  • Integrity of GI tract
  • Ability to Swallow or Access GI Tract
  • Perfusion of GI Tract

Acute Rate Control Options

• If no decompensated HF: Beta blocker or non-DHP-CCB preferred, digoxin (second-line), and amiodarone (third-line)
• If decompensated HF: Amiodarone preferred, do NOT use non-DHP-CCB

AF with Pre-Excitation

• Pre-excitation syndrome: Alternate electrical pathway exists in heart bypassing AV node.
• Leads to earlier ventricular activation & various syndromes (Wolf-Parkinson-White, Lown-Ganong-Levine, etc.)
• Avoid agents that block AV node (adenosine, non-DHP CCBs, beta blockers, and digoxin)
• Use agents that block the accessory pathway (e.g., procainamide, ibutilide) safe.

Acute Rhythm Control

• Possible reasons for cardioversion: unstable hemodynamics due to RVR, and presenting symptoms with a desire to achieve rate control.
• Drugs and electrical cardioversion.

Pharmacological Cardioversion

• Pros: No sedation required, ease of use, and no need for continuous monitoring.
• Cons: Inferior efficacy compared to direct current cardioversion (DCC), continuous monitoring may be required, and potential drug-drug interactions (DDIs).
• Normal LV Function Considerations: 1st-line (IV amiodarone and ibutilide), 2nd-line (procainamide) to manage those patients who present with HFrEF consider IV amiodarone.

Patient-Initiated Pharmacological Cardioversion ("Pill-in-the-Pocket" or PIP)

• Flecainide or propafenone can be used in a monitored setting for initial conversion, preferably with telemetry monitoring for at least 6 hours after the first dose.
• Efficacy is conversion to normal sinus rhythm (NSR).
• Concomitant beta-blocker or non-DHP CCB should be administered.

Patient-Initiated Pharmacological Cardioversion ("Pill-in-the-Pocket," or PIP) Inclusion/Exclusion Criteria

• Inclusion: Randomized patients with symptomatic, paroxysmal AF, at least two hours of sustained AF episodes occurring less frequently than once per month, and no disabling or severe symptoms, and capability to follow directions
• Exclusion: Structural heart disease(EF <50%, active ischemic heart disease, LVH), abnormal conduction (QRS, PR, pre-excitation), sinus node dysfunction or AV block, and patients who have previously shown intolerance to study drugs or have experienced hypotension.

Direct Current Cardioversion (DCC)

• Recommended when RVR does not respond quickly, in presence of ongoing myocardial ischemia, or symptomatic hypotension/heart failure
• Contraindicated in patients with digitalis toxicity.
• Advantages: immediate response, no DDIs or ADEs, and no need for extended monitoring, has shown superior efficacy compared to pharmacological cardioversion.
• Disadvantages: sedation and analgesia typically preferred.

Antithrombotic Therapy for Cardioversion

• Increased risk of thromboembolism following cardioversion, highest in the first 72 hours.
• Majority of thromboembolic complications occur within 10 days of cardioversion.

Peri-Cardioversion Anticoagulation

• Urgent cardioversion in hemodynamically unstable patients should ideally use therapeutic-dose, parenteral anticoagulation before cardioversion.
• Therapeutic- or elective-cardioversion in patients with AF of less than 48 hours, CHADSVASC > 2 should undergo TEE to rule out intracardiac thrombus. Starting anticogulants and proceeding with the cardioversion if there is not a thrombus.
• In patients with AF documenting an unknown or greater than 48-hour duration, option 1 is to use uninterrupted anticoagulation for 3 weeks prior to cardioversion and option 2 is a TEE-guided approach with abbreviated anticoagulation before cardioversion.

TEE-Guided Approach

• The mandatory 3-week anticoagulation period for elective cardioversion can be shortened if the TEE shows no thrombus in the LAA.
• Moderate-severe LV systolic dysfunction, left atrial spontaneous echo-contrast, complex aortic plaque, or low left atrial appendage velocities( ≤ 20 cm/s) on TEE are independent predictors of stroke.
• Anticoagulation options for TEE-guided strategy: IV UFH, LMWH (at full VTE doses), DOACs, or Warfarin.

Therapeutic Considerations in AF: Acute vs. Chronic

• Acute treatment prioritizes immediate hemodynamic stability and may involve rhythm control, anticogulants, or rate control.
• Chronic considerations focus on long-term management and prevention of progression, which may involve lifestyle changes, medication, and patient assessment.

Chronic AF Management

• Access to all aspects of care for all patients
• Optimize modifiable risk factors and treat stroke risk.
• Symptom management with rhythm control and/or rate control
• Shared-decision-making for stroke and bleed risks/treatments/patient preferences
• Lifestyle and risk factor modifications: Obesity, physical inactivity, unhealthy alcohol use, smoking, diabetes, hypertension.
• Risk stratification (CHA2DS2-VASc & HAS-BLED) with individualized patient assessments of stroke and bleeding.

Shared Decision Making (SDM)**

• Use evidence-based decision aids to guide stroke reduction therapy treatment decisions throughout the disease course.
• Improve quality of decision-making, patient engagement satisfaction.

Lifestyle and Risk Factor Modification (LRFM)

• Obesity: Weight loss to a BMI of 27 with target 10% weight loss
• Physical fitness: Moderate-to-vigourous exercise (210 minutes or more per week)
• Tobacco use: Strong recommendation to quit.
• Alcohol intake: Minimizing or eliminating consumption in those seeking rhythm control
• Caffeine intake: Abstention is not recommended.
• Hypertension: Optimal blood pressure control
• Sleep apnea: Screening and management should also be considered

Antithrombotic Therapy in AF

• Essential component of AF treatment.
• 15-20% of ischemic strokes occur in patients with AF.
• AF independently increases the risk of ischemic stroke by 4-5 times.

Chronic Antithrombotic Therapy in AF

• CHA2DS2VASC and HAS-BLED to estimate annual stroke and bleeding risk.
• Individualized risk assessments should be completed on a regular basis.
• Consider other pertinent tools, like ATRIA, GARFIELD-AF, or HEMORR2HAGES, including a history, in order to assess patient risk.

CHA2DS2VASc for Stroke Risk

• Congestive heart failure/LV dysfunction
• Hypertension
• Age ≥75
• Diabetes mellitus
• Stroke/TIA/thromboembolism
• Vascular disease
• Age 65–74
• Sex category (e.g., female sex)
• Maximum score (9)

CHA2DS2VASc Risk Assessment

• CHF (Congestive Heart Failure)
• HTN (Hypertension)
• Age
• Diabetes Mellitus
• Stroke/TIA/TE (Thromboembolism)

CHA2DS2-VASc Risk Assessment

• CVA/TIA/TE (Cerebrovascular Accident/Transient Ischemic Attack/Thromboembolism)
• Peripheral/pulmonary embolism, stroke, etc.

CHA2DS2-VASc Risk Assessment

• Vascular disease
• Prior MI, angina pectoris, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), peripheral vascular disease (PVD), abdominal/thoracic surgery, arterial or venous thrombosis.
• Sex (Female)

Risk Categories by CHA2DS2VASc Score

• Low risk: Non-sex CHA2DS2-VASc score of zero; stroke-risk reduction and oral anticoagulant therapy are not recommended; Aspirin monotherapy is preferable.
• Intermediate risk: A non-sex CHA2DS2-VASc score of one; stroke-risk reduction with oral anticoagulants may be reasonable; Monotherapy of ASA or DAPT as an alternative to anticoagulation isn't recommended
• High risk: non-sex CHA2DS2-VASc score >2; stroke-risk reduction therapy with oral anticoagulant is recommended; Monotherapy ASA or DAPT as an alternative to anticoagulation isn't recommended

Intermediate Risk and Therapy Selection

• Step 1: Look for other indications for anticoagulation (mechanical heart valves, moderate-to-severe mitral stenosis, etc.)
• Step 2: Assess benefit vs. risk by considering yearly risk of thromboembolism and patient's bleeding risk (HAS-BLED score)
• Step 3: Shared decision-making (discussion of risks and preferences).

HAS-BLED for Bleeding Risk

• Hypertension
• Abnormal liver/kidney function
• Stroke
• Bleeding
• Labile INR
• Elderly
• EtOH
• Drugs.

Assessing Bleeding Risk

• Modifiable factors: Uncontrolled blood pressure, INR control, concomitant drug therapy, excessive alcohol intake, avoidance of hazardous hobbies/occupations, avoidance of bridging therapy, choosing appropriate OAC.
• Potentially modifiable factors: Frailty, anemia, reduced platelet counts/function, and renal impairment.

Other Bleeding Considerations

• Falls: Evaluate home environment, physical therapy, assistive devices, and neurological assessment may be beneficial
• Cognitive impairment: Consider caregiver presence to ensure adherence to the medication-taking schedule
• Regular Medication reviews
• Medic alert bracelet
• Intensive counseling for OTC medication selection.

Oral Anticoagulants (OAC) for Stroke Prevention

• DOACs are recommended over VKA, with exceptions for severe rheumatic mitral stenosis or mechanical heart valves.
• For VKA patients with low TTR, consider intervention for higher TTR or a switch to DOAC.
• Antiplatelet therapy is not a sole strategy for stroke prevention in patients with AF.

DOAC vs NOAC Terminology

• Pradaxa approval
• Variable use in guidelines; International Society of Thrombosis and Haemostasis recommends using DOAC instead of NOAC for clarity
• DOAC can be interpreted as "No Anticoagulation" or "No AC" (cited in ISMP documents).

DOAC Considerations

• Renal function: All DOACs have some renal elimination but Apixaban was only approved for those with ESRD
• Hepatic function
• Drug-drug interactions
• Dosing burden
• Swallowability
• Food/GI considerations: Avoid in those considered high-risk for GI bleeds.
• Asian ethnicity:

DOAC Monitoring Recommendations

• Kidney: CrCl > 60 (every 6 months), CrCl 30-59 (every 3 months), CrCl ≤ 30 (every 1-2 months).
• Liver: Child-Pugh A (every 6 months), Child-Pugh B (every 3 months), Child-Pugh C (every 1-2 months).
• RBC: (Hgb/Hct), HAS-BLED 0-2 (every 6 months), HAS-BLED ≥3 (every 3 months) and other pertinent risk factors may be assessed here.

DOAC Contraindications

• Mechanical heart valves
• Moderate/severe mitral stenosis
• Hepatic disease with clinically significant coagulopathy or bleeding.

DOAC Dosing

• Varying dosing for AF vs. other indications.
• Varying dosage reduction recommendations between agents

VKA Therapy

• Reduced pro-coagulant activity on vitamin K-dependent clotting factors.
• Two isomers: R and S; half-life (different from each other);
• Goal therapeutic INR: 2.5 (range 2 - 3)
• Initiate dosing to achieve steady-state INR.
• Monitoring frequency: Not uncommon to check and adjust daily in hospitalized patients
• Therapeutic conundrum: warfarin loading

INR Monitoring

• INR values outside the therapeutic range place patients at risk.

Rosendaal method

• Calculates total change in INR between two consecutive measurements
• Calculated percent total change that falls within the target range will help assess the TTR.
• TTR < 65% requires intervention, optimal TTR >70%

SAMe-TT2R2 for TTR Prediction

• A score that considers risk factors (sex, age, medical history, treatment with interacting drugs, tobacco, and race) for achieving good TTR on VKA
• Scores of 0-2 are likely to achieve good TTR, scores > 2 less likely.
• This score can also help predict ability to adhere to medication regimen.

Bridging Therapy for Planned Procedures

• Stop VKA (usually 5 days prior to the procedure).
• Start full-dose LMWH (usually 3 days prior to the procedure).
• Have the procedure.
• Resume VKA and LMWH following the procedure.
• Stop LMWH when INR is therapeutic in two consecutive measurements.

The BRIDGE Study

• Bridging does not reduce the risk of thromboembolism, but it does increase the risk of bleeding.
• Inclusion criteria: Patients ≥ 18 years old with confirmed, chronic AF, on warfarin for 3+ months, planned procedures requiring warfarin interruption.
• Exclusion criteria: patients with mechanical heart valves, CVA/TIA/systemic embolism in previous 12 weeks, major bleeding in the previous 6 weeks, CrCl < 30 ml/min, and those who have had recent cardiac or cranial surgery.

Do I Bridge?

• High-risk patients: TIA or CVA within the last 3 months, prior perioperative CVA, CHADS2VASc score ≥ 7, CHADS2 score ≥ 5.
• AHA (2020): Use assessment of balance of risk of stroke vs. bleed risk (duration of interruption).
• Consideration of mechanical heart valves.

Valvular AF: Historical Perspective: RE-ALIGN Trial

• Trial was terminated prematurely due to excess thromboembolic and bleeding events for the dabigatran group.
• Reduction of stroke/systemic embolism risk in patients without mechanical valves.
• RE-ALIGN excludes moderate to severe mitral stenosis patients.

Valvular Heart Disease: Historical Perspective

• Mechanical prosthetic heart valves and moderate to severe mitral stenosis
• Exclusionary criteria in DOAC trials.

Evaluated Heart Valves, Rheumatic or Artificial (EHRA)

• EHRA Type 1: Patients with VHD needing VKA (DOACs contraindicated) - mechanical prosthetic heart valves, moderate to severe mitral stenosis.
• EHRA Type 2: Patients requiring OAC with either VKA or DOAC- all native/other valvular diseases, valve repairs, replacements, and TAVI.

Selected Indications and Contraindications for Non-Vitamin K Antagonist Oral Anticoagulant Therapy

• Mechanical prosthetic valve, moderate/severe mitral stenosis (contraindicated), mild/moderate valvular disease (included in NOAC trials).
• Severe aortic stenosis (limited data), bioprosthetic/mitral valve repair (after 3+ months post-operative).
• PTAV/TAVI (Transcatheter Aortic Valve Implantation).
• Hypertrophic cardiomyopathy.

Ensuring Adherence to OAC Therapy

• Patient education
• Family involvement
• Predefined follow-up schedule
• Align dosing regimen with daily schedule
• Technology aids

Contraindication to OAC

• Long-term vs. Short-term contraindications.
• Severe bleeding, related to a nonreversible cause, spontaneous CNS bleed, or serious recurrent bleeding.
• Treat short-term contraindications (easily corrected/mitigated)

LAA Closure Devices

• WATCHMAN or WATCHMAN FLX™ Device.
• Indication: Patients with AF with an increased risk of stroke who have contraindications to long-term anticoagulation.
• CMS Requirement: CHADSVASc ≥3

WATCHMAN® FLX Post-Operative Plan

• DOAC (apixaban or rivaroxaban) + low-dose aspirin (45 days).
• DAPT (ASA 75-81 mg) for 6 months
• ASA (75–81 mg) lifelong.

Other LAA Closure/Exclusion Options

• Amplatzer Amulet, Wavecrest, PLAATO, WaveCrest, Ultraseal, Lariat, Atriclip, and Sierra are examples.

Chronic AF Management

• Access to all components of patient care
• Treatment of stroke risk and optimization of modifiable risk factors
• Symptom management (rhythm/rate control)
• Shared decision-making on stroke & bleeding risks/therapies
• Lifestyle and risk factors (obesity, physical activity, unhealthy alcohol & tobacco use, diabetes, and hypertension.)

Rate vs. Rhythm Control

• Initial treatment approach was to determine whether rate or rhythm control was the best option for treatment and management, however, there is no clear superiority.

Early Rhythm Control

• Recent investigations on the impact of early rate control selection (N=2,789).
• Inclusion criteria: Early AF (dx ≤1 year), age > 75 years
• Intervention included: antiarrhythmic drugs, ablation, or cardioversion, all patients also received anticoagulation and rate control.
• Primary outcome was composite safety outcome defined as death, stroke, or serious adverse events.

Selecting Rate Control Goals: RACE II Trial

• Lenient (resting HR < 110 bpm) vs. Strict (resting HR < 80 bpm)
• No statistically significant difference in 3-year outcomes (no difference in mortality, left ventricular function, symptom scores, or quality of life).

Drugs for Long-Term Rate Control

• Beta blockers: Helpful in high adrenergic conditions; Combination with digoxin is safe.
• Non-DHP CCBS: Should be avoided in those with HFrEF due to potential negative inotropic effects.
• Digoxin: Effective in controlling resting HR, but potential concerns for adverse effects/drug interactions during exercise and renal elimination, and increased mortality at > 1.2 ng/mL concentration.

Non-Pharmacological Rate Control

• AV node ablation: Selective catheter-mediated destruction of the AV node or Bundle of His, which often results in complete heart block (irreversible).
• Cardiac pacemaker placement may be subsequently required after the procedure.

Patient-Tailored Therapy

• How will permanent AF/symptoms affect the patient?
• Is the drug tolerable / How successful will rhythm control be expected to be?

Rhythm Control

• In patients with AF diagnosed less than 1 year, rhythm control may reduce hospitalizations, stroke, and mortality rate, however, can contribute to dementia and worsening of cardiac heart structure.
• Strict control of risk factors alongside avoidance of triggers must be included as part of the rhythm control strategy.

Therapeutic Options for Long-Term Rhythm Control

• Amiodarone (Cordarone, Pacerone)
• Dofetilide (Tikosyn)
• Dronedarone (Multaq)
• Flecainide (Tambocor)
• Propafenone (Rhythmol)
• Sotalol (Betapace AF)

AAR Selection

• Dofetilide, dronedarone, flecainide, propafenone as first-line agents (for those without heart disease)
• Amiodarone or Sotalol as a second-line
• Sotalol as a third-line
• Proper consideration of renal and hepatic dysfunction, and other factors influencing drug use

TABLE 24Recommended Monitoring for Patients Taking Oral Amiodarone

• Hypo/hyperthyroidism
• Hepatotoxicity
• QT prolongation, interstitial lung, corneal microdeposits (keratopathy), and dermatologic and neurological issues are all tracked in patients taking this drug.

Antiarrhythmic Drug-Drug Interactions

• Dofetilide has drug-drug interactions with renal cation transport system inhibitors (CIM, dolutegravir, ketoconazole, megestrol, prochlorperazine, trimethoprim, verapamil), Hydrochlorothiazide (HCTZ)
• Amiodarone, dronedarone, flecainide, and propafenone have interactions with some CYP enzymes, 3A4/2D6/2C9, and P-gp.

Non-Pharmacological Rhythm Control

• Catheter ablation: Gaining acceptance;
• Pulmonary vein isolation (PVI) as first-line therapy.
• Appropriate for symptomatic paroxysmal or persistent AF.
• Important to consider patient populations.
• Peri-Catheter Ablation Stroke Risk Management to follow.

Test your knowledge on the management of atrial fibrillation, focusing on the HAS-BLED and CHA2DS2VASc scoring systems. This quiz covers bleeding risk factors, anticoagulation therapy considerations, and essential clinical decisions in patient care. Assess your understanding of stroke risk and treatment recommendations for patients with AF.