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ef Lucrri dr. Viviana AURSULESEI

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FIBRILAIA ATRIAL: DE CE?

Cea mai frecvent tulburare de ritm

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FIBRILAIA ATRIAL: DE CE?

Incidena crete n timp dar i cu vrsta

Prevalen dubl > 50 ani

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FIBRILAIA ATRIAL: DE CE?

Asociat cu morbiditate crescut: risc estimat AVC x 5

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FIBRILAIA ATRIAL ESTE O CONDIIE FRECVENT SILENIOAS CUCONSECINE SERIOASE APARIIA AVC 30%

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FIBRILAIA ATRIAL I CREIERUL: dincolode AVC

Studii clinice Adult Changes in Thought

Study OnTarget, Transcend

Mecanisme via AVC ischemic Embolii silenioase Hipoperfuzie cerebral Inflamaie

Disfuncie microvascular

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FIBRILAIA ATRIAL: ce factori de risc?

....i nu numai

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FIBRILAIA ATRIAL: ce mecanisme?

Factori atriali Factori

electrofiziologici

Predispoziie

geneticREMODELAREELECTROANATOMC

SDR. CARDIACEMOTENITEMECANISM FOCALMULTIPLEWAVELET"

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FIBRILAIA ATRIAL: consecineConducere atrio-ventricular

Modificri hemodinamice

Tromboembolism

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Pacientul tnr cu fibrilaie atrial

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M.A., 24 ani07. 12. 2011 APP: fr AHC: nesemnificative Nefumtor, neconsumator de alcool Istoric: uoar fatigabilitate la efort de aproximativ 3 luni,

palpitaii Clinic: FC=120/min, fr sufluri, TA=120/80mmHg zgomote cardiace aritmice, deficit de puls

Diagnostic clinic: fibrilaie atrial

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PRIORITATE CHEIE: detecie i diagnostic

Casedetection

Assessment

Rate-

control

Rhythm-

control

Referral

Follow-up

Follow-up

O

R

An ECG should beperformedin all patients, whether

symptomatic or not, inwhom AF is suspectedbecause an irregularpulse has been

detected

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Diagnostic clinic: fibrilaie atrial

ECG

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Algoritm diagnostic: ntrebri cheie?

CARACTERIZAREA FIBRILAIEI ATRIALE

ESC Guidelines 2010 on the management of Atrial Fibrillation

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Algoritm diagnostic: ntrebri cheie?

CARACTERIZAREA FIBRILAIEI ATRIALE

ETIOLOGIE

VECHIME

SIMPTOME

ESC Guidelines 2010 on the management of Atrial Fibrillation

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CONDIII PREDISPOZANTE SAU CARE MENINFIBRILAIA ATRIAL

European Heart Journal,2010

FIBRILAIA ATRIALIDIOPATIC("lone AF")

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I. BILAN ETIOLOGIC

Ex.C-V: normal

Ecocord: normal

colesterol=183mg% trigliceride=130mg%

glicemie=98mg%

TSH=2,68UI/ml FT4=16,89pmol/l

FA IDIOPATIC

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II. Vechimea fibrilaiei atriale

ESC Guidelines 2010 on the management of Atrial Fibrillation

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FIBRILAIA ATRIAL: CUM TRATM?

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CE CONDUIT LA PACIENT?

TRATAMENTOPTIM?

PACIENT TNR, ACTIV CONTROLUL SIMPTOMELOR

TRATAMENTOPTIM?

FR BOAL STRUCTURAL CARDIAC CONTROLUL FRECVENEI VENTRICULARE? CONTROLUL RITMULUI CARDIAC?

TRATAMENTOPTIM?

EVALUARE RISC TROMBOEMBOLIC CUM?

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CONTROLUL FRECVENEI VENTRICULARESAU A RITMULUI?

ESC Guidelines 2010 on the management of Atrial Fibrillation

FA PAROXISTIC/PERSISTENT BOAL STRUCTURAL CARDIAC

ABSENT/CAUZ CORECTAT PACIENT TNR, ACTIV,

SIMPTOMATIC

CONTROL RITM

CARDIOVERSIE

EEC CARDIOVERSIE FA PERMANENT FA SECUNDAR UNOR CAUZE CE NU SUNT

CORECTATE /CORECTABILE VECHIMEA FA BOAL DE NOD SINUSAL/BOAL BINODAL PACIENT VRSTNIC REFUZ PACIENT PENTRU CARDIOVERSIE

CONTROL FRECVENVENTRICULAR

POATE FI I O SITUAIETEMPORAR!!

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CONTROLUL FRECVENEI VENTRICULARESAU A RITMULUI?

ESC Guidelines 2010 on the management of Atrial Fibrillation

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CONTROLUL RITMULUI N FA PAROXISTIC:CARDIOVERSIA FARMACOLOGIC

ESC Guidelines 2010 on the management of Atrial Fibrillation

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CONTROLUL RITMULUI N FA PERSISTENT

ESC Guidelines 2010 on the management of Atrial Fibrillation

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OPIUNE TERAPEUTIC LA PACIENT07.12.2011: Bisogamma 5mg/zi, Sintrom 2mg/zi

18.01.2012: INR 2,36 Cardioversie electric RS

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EVOLUIE: meninerea RS

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POSTCARDIOVERSIE

CE ATITUDINE PENTRU MENINEREARITMULUI SINUSAL?

PROFILAXIE

ANTIARITMIC

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PRINCIPII DE TERAPIE ANTIARITMIC pentruMENINEREA RITMULUI SINUSAL I)REALITATEA PRACTICVERSUS INDICAII

1. Tratamentul este motivat pentru a reduce simptomele induse de FA

2. Eficiena drogurilor antiaritmice n meninerea RS este modest

3. Terapia antiaritmic de succes mai degrab reduce dect eliminrecurenele FA

4. Dac un drog antiaritmic eueaz, se poate alege un alt drog

5. Proaritmiile induse de droguri sau efectele extracardiace sunt frecvente

6. Alegerea de prim intenie a unui drog antiaritmic trebuie ghidat desigurana administrriii apoi de eficien!

ESC Guidelines 2010 on the management of Atrial Fibrillation

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PRINCIPII DE TERAPIE ANTIARITMIC pentruMENINEREA RITMULUI SINUSAL II)

ESC Guidelines 2010 on the management of Atrial Fibrillation

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PRINCIPII DE TERAPIE ANTIARITMIC pentruMENINEREA RITMULUI SINUSAL III)

ESC Guidelines 2010 on the management of Atrial Fibrillation

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CONDUITA TERAPEUTIC POSTCARDIOVERSIE LAPACIENTPROFILAXIE ANTIARITMIC: PROPAFENON 45O mg/zi

ESTE NECESARTROMBOPROFILAXIE?

CUM DECIDEM INDICAIA DE TROMBOPROFILAXIE?

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CUM DECIDEM INDICAIA DE TROMBOPROFILAXIE?

Stratificare risc AVC

SCOR CHADS2Risk factor Points

C Recent Congestive heart failure exacerbation 1

H Hypertension 1

A Age 75 years 1

D Diabetes mellitus 1

S Prior history of Stroke or transient ischemic attack 2

ESC Guidelines 2010 on the management of Atrial Fibrillation

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SCORUL DE RISC MBUNTITCHA2DS2-VASc

*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary

cohorts may vary from these estimates.

ESC Guidelines 2010 on the management of Atrial Fibrillation

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ANTIAGREGARE SAU ANTICOAGULARE?

ESC Guidelines 2010 on the management of Atrial Fibrillation

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CONDUITA TROMBOPROFILACTIC:ntre beneficiu i riscScorul de risc HAS-BLED

SCOR 3 = RISC NALT DE SNGERARE

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CONDUITA TERAPEUTIC POSTCARDIOVERSIELA PACIENTPROFILAXIE ANTIARITMIC: PROPAFENON 45O mg/zi

TROMBOPROFILAXIE CU ASPENTER 75 mg/zi

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EVOLUIE SUB TRATAMENT

Recurena fibrilaiei atriale, asimptomatice

Bisoprolol 5 mg/zi, Aspenter 75mg/zi (CHADS=0)

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CE OPIUNI N CAZ DE RECUREN?

2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)

2006 Recommendations 2011 Focused Update Recommendations

Class IBefore initiating antiarrhythmic drugtherapy, treatment of precipitating orreversible causes of AF is recommended.(Level of Evidence: C)

1. Before initiating antiarrhythmic drug therapy,treatment of precipitating or reversible causes of AF isrecommended. (Level of Evidence: C)2. Catheter ablation performed in experienced centers* isuseful in maintaining sinus rhythm in selected patients

with significantly symptomatic, paroxysmal AF who have

failed treatment with an antiarrhythmic drug and havenormal or mildly dilated left atria, normal or mildly

reduced LV function, and no severe pulmonary disease.3851 (Level of evidence:A)

Class IIa

In patients with lone AF without structuralheart disease, initiation of propafenone orflecainide can be beneficial on an outpatient basis inpatients with paroxysmal AF who are in sinus rhythmat the time of drug initiation. (Level of Evidence B )

In patients with AF without structural orcoronary heart disease, initiation ofpropafenone or flecainide can be beneficialon an outpatient basis in patients withparoxysmal AF who are in sinus rhythm atthe time of drug initiation.5254 (Level of Evidence B )

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CE OPIUNI N CAZ DE RECUREN?NLOCUIREA CU UN ALT DROG

2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)

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DRONEDARONE N FIBRILAIA ATRIAL: CND?2011 Focused Update Recommendations CommentsClass IIa1. Dronedarone is reasonable to decrease the need forhospitalization for cardiovascular events in patients withparoxysmal AF or after conversion of persistent AF.Dronedarone can be

initiated during outpatient therapy

Class IIIHarm1. Dronedarone should not be administered to patientswith class IV heart failure or patients who have had an

episode of decompensated heartfailure in the past 4 weeks, especially if they havedepressed left ventricular function (left ventricularejection fraction 35%)

New recommendation

New recommendation

2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)

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DRONEDARONE N FIBRILAIA ATRIAL

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CE ALTE OPIUNI N CAZ DE RECUREN:INDICAIA DE RADIOABLAIE

ESC Guidelines 2010 on the management of Atrial Fibrillation

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CE ALTE OPIUNI N CAZ DE RECUREN:INDICAIA DE RADIOABLAIE

ESC Guidelines 2010 on the management of Atrial Fibrillation

STADIULAFECTRII

ATRIALE

BOALSTRUCTURALCARDIAC

OPIUNIALTERNATIVE

TIP FA ISTORICUL FA MRIME ATRIU STNG

PREZENT ABSENT

MEDICAIE ANTIARITMIC

CONTROLUL FC ALEGEREA PACIENTULUI

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CONDUIT LA CAZ: opiuneapacientului este un factor cheieConsult specialist electrofiziologieSe poate tenta ablaia fibrilaiei atriale (izolare de vene pulmonare)

Cost 6000 euro

Rata de succes 70% 1 an; 50% 5 ani

O nou

cardioversie electric

+FLECAINID

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ABLAIA PE CATETER: opiune lapacient? Da, numai dac: exist recuren dup toate

antiaritmicele

acceptat de pacient

Este opiunea de preferat latnr vs amiodaron

ABLAIA PE CATETER

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critical fibres

microcircuitsof reentry

focal triggers

ABLAIA PE CATETER

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ABLAIA PE CATETER

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ABLAIA PE CATETER:sumar practic UTIL DOAR DAC:

este practicatn centrespecializate!

s-a epuizat eficienaantiaritmicelor

este preferat de pacient deprim intenie

pe termen lung nu a aprutrecurenn primele 6sptmni

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Antiaritmicele ntre beneficiu i risc

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M.E.,73 ani, 02. 12. 2010

MI: palpitaii

APP : 1980: HTA

18.XI.2010: FA paroxistic (monitorizare ECG Holter)tratat cu: Cordarone 400mg/zi, 14 zile, ulterior 600mg/zi

anticoagulare oral

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QT=520msec(+40%)

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EVOLUIE N SPITAL

Episoade de palpitaii Repetate episoade de convulsii, cianoz,

pierderea strii de contien

CAUZA?

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CE CONDUIT?

IIIMONITORIZARE ECG n evoluie

IICARDIOSTIMULARE ELECTRIC

TEMPORARPACING ANTI-TAHICARDIC

IEE (repetate) MgSO4, xilin p.i.v.

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EVOLUIE

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EVOLUIE Regresia intervalului QT

Monitorizarea ECG Holter 10.12.2010

un episod de fibrilaie atrial paroxistic

Atitudine terapeutic

betablocant

anticoagulare oral permanent controlul valorilor TA

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B.E., 73 ani, 16. 01. 2012

MI: palpitaii,ameeli, dispnee APP:

HTA

DZ tip 2

Dislipidemie

Obezitate (IMC=42 Kg/m2)

AVC (infarct occipital stng) - 2005 FA persistent (redus cu Cordarone) - 2010

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TRATAMENTAntiaritmic :Cordarone

200mg/zi

AnticoagulantAntihipertensive:diuretic +

inhibitor ACE Hipolipemiant: statin

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FLUTTER ATRIAL 1/1

COMPLICAIE EXTREM DE RAR LA CORDARONE

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BILAN FUNCIONAL Uree=65mg%

Creatinina=0,73mg%

Glicemie=148-128mg%

Na=141mEq/l K=4,6mEq/l

RA=25mEq/l TSH=67,41ui/ml; FT4=11,53pmol/l

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QT= 440msec

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AMIODARONA: ce alte efecte adverse?

Smurf Drug

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EVOLUIE I ATITUDINE TERAPEUTIC Tratament antihipertensiv Tratament anticoagulant Tratament de substituie tiroidian

Meninerea RS fr tratament antiaritmic

Exist riscuri? Da: nou episod de FA risc crescut de AVC

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CE ATITUDINE DUP CONTROLULHIPOTIROIDIEI? Anticoagulare strict

Controlul frecvenei ventriculare:

60-80/min n repaus 90-115/min la efort

Ce medicaie?

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CE DROGURI?

CE ATITUDINE ESTE DE PREFERAT?

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Stroke Prevention in Atrial Fibrillation

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Unpredictable

response

Routine coagulation

monitoring

Slow onset/offset

of action

Risk of Bleeding

Complications

Anticoagulation

therapy has

several

limitations thatmake it difficult

to use in

practice

Numerous drug-drug

interactions

Numerous food-drug

interactions

Frequent dose

adjustments

Narrow therapeutic

window

(INR range 2-3)

Limitations of Anticoagulation Therapy in Atrial Fibrillation

OAC was #1 in 2003 and 2004 in the number of mentions of deaths fordrugs causing adverse effects in therapeutic use

OAC caused 6% of the 702,000 ADEs treated in the ED/year; 17% requiredhospitalization

J Thromb Thrombolysis 2008; 25: 52-60

New antithrombotic treatments in Phase III trialsfor stroke prevention in atrial fibrillation

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p

Tissue Factor

Plasma ClottingCascade

Prothrombin

Thrombin

Fibrinogen Fibrin

Thrombus

Platelet Aggregation

ConformationalActivation of GPIIb/IIIa

Collagen

Thromboxane A2

ADP

AT

Aspirin

ClopidogrelPrasugrel

AZD6140

Dabigatran

Ximelagatran

FactorXa

Idraparinux

ApixabanRivaroxaban

Edoxaban

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ANTICOAGULANTE ORALE NOI

Dabigatran

Rivaroxaban

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ANTICOAGULANTE ORALE NOI

Nu sunt inferiori n preveniaAVC/embolii n FA

Risc redus de hemoragii fatale,inclusiv intracerebrale

Risc crescut de HDS

Nu necesit monitorizarea

coagulrii

Dabigatran

Rivaroxaban

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ANTICOAGULANTE ORALE NOIFeatures Warfarin New agents

Onset Slow Rapid

Dosing Variable Fixed

Food/drug interactions Many None or very few

Monitoring Yes No

Half life Long Short

Antidote Yes No

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Recommendation for Combining Anticoagulant

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With Antiplatelet Therapy2011 Focused Update Recommendation Comments

Class IIb

1. The addition of clopidogrel to aspirin(ASA) to reduce the risk of majorvascular events, including stroke, mightbe considered in patients with AF inwhom oral anticoagulation with warfarinis considered unsuitable due to patientpreference or the physicians assessment

of the patients ability to safely sustain

anticoagulation.10 (Level of Evidence: B)

New recommendation

2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)

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NCHIDERE URECHIU AS

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