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Rate vs. Rhythm Control for Atrial Fibrillation

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Heart rate vs. rhythm control vs. rhythm restoration was the focus of Dr. Paul Wang’s talk at Piedmont Heart’s Napa Valley Cardiology Conference. Dr. Wang, director of Stanford’s Cardiac Arrhythmia Service, discusses the overall treatment guidelines for the management of patients with atrial fibrillation (AF) and reviews the recent 2017 AF ablation guidelines with “an important new emphasis on surgical ablation for our field.”

Okay great so i’ll be talking about excuse me rate rhythm control overall and so i’ll run you through where we are in the guidelines and i’m gonna editorialize a fair amount in terms of what my practice is so this is the latest document regarding overall treatment i’ll talk about the 2017 a-fib guidelines it’s just ablation a guidelines it just came out but this

Is regarding the overall management so i’ve highlighted the issues about rate control and a lot of this is pretty straightforward you know basically beta-blockers non hydro pyridine calcium channel blockers are used for a rate control but what about what are our goals so this is listed as a – a rate control that is at rest a heart rate goal of less than 80 but

What about more lenient strategy and so i put in the bottom there trial called race to which looked at lenient or strict control and as you can see that basically there was no statistical significant difference in fact may be lenient control was a little better in terms of outcomes and so that’s listed as a 2b indication less than 110 so i think that remains a

Consideration as to are we over a rate controlling many people they come in with fatigue because we’ve now made them very bradycardic and sinus for the paf patients etc so i think that becomes a real consideration that we do consider in daily practice av node ablation i think we do much less of than we used to and it’s a class-3 indication in terms of you must

Try other rate control agents first so this is the overall view you can see that most of the agents are used pretty interchangeably in most disorders the major limitation that being of lv dysfunction or heart failure where we avoid calcium channel blockers generally what about rhythm control and so this is a conversion so the guidelines indicate fleck and i

Do fit allied for poppin own or iv i butyl id are used for rhythm control and conversion and then in its to a were considered either oral amiodarone for pharmacologic conversion or a pill in the pocket and the the caveat indicated is that this would be observed to be safe in a monitor setting typically an emergency department kind of setting before going ahead

And recommending routine pill of the pocket until fed allied limited to initiation in the hospital so what about this whole issue of then deciding ablation and that’s what i’ll kind of concentrate on so class one indication if you’ve seen here is really that of symptomatic paroxysmal atrial fibrillation that has been a refractory or intolerant to typical medical

Therapy so that’s the highest in terms of the classification and i think that remains such in most of our practices but what about expansion of this and so when you look at the 2a indications it extends to sympathy in a symptomatic persistent afib that’s been refractory intolerant to class one or three agents so why the difference why was persistent included in

The 2a and paroxysmal in the class in the class one well again it’s i think recognition of benefit the benefit as we’ll talk about further is greater in paroxysmal atrial relations a higher success rates for single procedures and that remains to today the other part of it is the second point in class 2a it says that catheter ablation for symptomatic paroxysmal

Atrial fibrillation is an alternative so for the firt you know one of the first times it can be first-line therapy and that’s a 2a indication so that is also acceptable overall so this is the schema that was given to us in terms of that you see again the possibility of going to catheter ablation early versus going through multiple forms of drug therapy and or

In the drug therapy what about surgical therapy we have a few surgeons in the in the room here i understand so what about that so 2a in fact some of the early guidelines did not even include cardiac surgery so i think most of us were very delighted to see that it’s reasonable in patients undergoing cardiac surgery and that’s changed a little bit as you’ll see

In the 2017 guidelines speaking of the 2017 guidelines these were released last month you can see that similar kind of at ear level for symptomatic afib refractory to at least one drug so it’s class one still for paroxysmal afib class 2a still for persistent and then long-standing again a recognition that long-standing persistent afib catheter ablation has even

A lower success rate it’s a to b now so that’s the kind of the tier thinking we have in terms of in a use of catheter ablation in these settings this is what i refer to that is this is titled concomitant such as mitral valve surgery in atrial fibrillation and now symptomatic afib is a class one indication so i think again a recognition that there is a role for

Surgical treatment in concomitant surgery where they’re having a valve procedure or other cardiac procedures so again i think a call-out to an important new emphasis for surgical ablation in our field okay but we’re left with this dilemma okay what about rhythm control versus rate control and then what’s the overall picture so i pulled out a study from the ncdr

Pinnacle which my colleague came into taraki as a co-author on and so it gives us some real-world i think insights into what is really being done and so you see here this is over about a half a million patients with atrial fibrillation this is a diverse population but you see that three-quarters were not treated with rhythm control and that’s why it’s described

Leaving about a you know 20 so percent with rhythm control of those that is of the people who were in rhythm control ablation was only used in 13 percent so you see that ablation is really over this time period has remained a relatively modest proportion in terms of our therapy so you may get a very different picture in many of the tertiary care centers represented

Here where you think well everybody gets ablated don’t they but clearly the real world says something very different about this and some of the interesting insights in terms of this paper provided i think were some of the factors and so those are some of the things listed here there are a number of things that were predictors of the use of rhythm control so if

You’re younger male gender white race or example private insurance a number of factors that are both medical and non-medical you could argue we’re basically important in determining who is going to get rhythm control and this is further seen when you see who gets catheter ablation as well so these are a number of factors that i think we as a field have to kind of

Grapple with well how are we making these decisions probably not really based on different people in this room but the overall a group of people who see patients with atrial fibrillation how are they making these decisions and so that’s really i think a call out to our field broadly that is a non cardiologists of trying to educate them and understand what decision

Makings and options are are particularly as our therapies advance the other comment i would say is that when you look at successes that are quoted in trials i would say single center successes are dramatically higher than that when you when you starts getting multicenter trials and i think some of the lowest are those which are a multicenter fda trials i personally

Regard if the multicenter fd browses some of our best trials meaning that they’re least likely to be selected and but still very high quality data so you really have to kind of wonder when you look at some single center studies even very large robust ones from outstanding centers is that reproducible across the country and are you generalizing when you’re basing

Your guidelines and clinical practice on those studies so i’ll kind of guide you through where we are and the terms of ablation and success and you can see on this you know kind of a slide some of the you know what’s happened over the years well 60 percent has become 70 percent you know that kind of range up until probably about you know five or six years ago

This is the latest this was published the last year called fire and ice comparing two of our latest technologies cryoballoon as many of you know has increased at a much more rapid rate than i think most people can estimated and now as an increase in proportion of the overall world experience and us experience with catheter ablation in this study was really the

First large randomized multicenter trial comparing greater fruits and cryoablation and as you see the take-home message is that they were non-inferior you see though that the success overall is about 60 to 65 percent at you know one year’s time so not you know something like eighty or ninety percent either as you see in this you know group of quite experienced

Centers when you look further is there a difference in generation yes probably so that is the more advanced technology does seem to have a benefit but still maybe only a modest one getting yupped up 70% compared to 60 years so when you look at other endpoints there is somewhat of a benefit of cryoablation versus radiofrequency that isn’t all caused hospitalization

Cardiovascular hospitalization or freedom from repeat ablation there is some benefits seen for cryoablation but yet this has to be reproduced in multiple other centers i think and studies in the future okay this is another this is called a post market approval fda study as you know the fda is required meant in addition to the initial pivotal studies more and more

Studies that are needed in terms of post approval and this gives you a look at probably 80% freedom from 88 really echo cardi atrial fibrillation and flutter at one year so we’re seeing some increase going from the 60 to 70 probably up to the 80% in pa f the next biggest controversy is what can we do what’s the best strategy that is is it anatomic like pulmonary

Vein ablation which we’ve seen in the previous slides on radio ferguson catheter ablation or is there a way to map atrial fibrillation so this is i think one of our biggest challenges in terms of answering this question this slide i show here is actually on an interesting ex-vivo study these are explanted human hearts at a time of heart transplantation and have

Done some very nice optical mapping that tries to demonstrate yes there is some ability to map atrial fibrillation and that remains a big question what can we do clinically can we actually do that in a clinical way this is a slide provided by my colleague stanton ryan who developed this and you can see on the upper left panel you can see this little red dot moving

Around it’s like one of those dots you read you know you’re trying to sing along and you’re kind of looking at to see how that moves and instead of being kind of scattered you see the ability to be able to track this you know like the so called eye of the storm and so this is the whole principle of this so-called firm mapping that has been done focal impulse and

Rotor mapping which is now being studied to guide a catheter ablation and their number of studies underway and we’re waiting for those multicenter trials to be done this is a very important trial that looked at persistent afib but one of the key issues here was can we do more than pulmonary vein isolation i think generally the feel that said yeah for sure things

That you do beyond pulmonary vein isolation always seem to benefit now this is a major randomized trial that looked at this and it showed no benefit b a pulmonary vein isolation so i think that the jury’s still out as what are the different things that we can do to improve outcomes and that’s part of the next discussion this is the work of using a social hybrid

Surgical catheter ablation again non randomized but show that potential for persistent in atrial fibrillation to be treated with higher to wreak success with this so-called combined reaching success is about eighty to ninety percent off drug so what are some of the take-home messages atrial fibrillation symptoms can be reduced by catheter ablation the second

Degree generation success is probably increased further probably in the eighty plus not 80 plus percent there our patient populations that remain challenges persistent afib long-standing persistent atrial fibrillation large outlift atrial sizes and that success may be 50 percent we need to learn much more about mapping that may provoke improve success in the

Future risk modification which we’d love to talk about also has a large impact that is weight reduction sleep apnea treated treatment and other techniques such as hybrid surgical ablation may have some promise for the future thank you very much you

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Rate vs. Rhythm Control for Atrial Fibrillation By Piedmont Heart Institute