1、Cardioversion of Atrial Fibrillation Clinical Issues,Christopher Granger, MD Director, Cardiac Care Unit Duke University Medical Center December 2007,Cardioversion of Atrial Fibrillation Clinical Issues,When and why cardiovert? Why not wait for spontaneous cardioversion? When and why acutely cardiov
2、ert? How to acutely cardiovert Electrical Pharmacologic Both,AFFIRM Baseline Characteristics,Age = 69.7 9.0 yrs 39% female 2 days of AF in 69% CHF class II in 9% Symptomatic AF in 88%,Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) Trial (n=522),Van Gelder, I.
3、et al. N Engl J Med 2002;347:1834-1840,CV death, HF, thromboembolic complications, bleeding, pacemaker, and SAEs.,Trials of Rate vs Rhythm Control,ACC/AHA/ESC Guidelines 2006,Implications of Trials: Guideline Statement,Theoretically, rhythm control should have advantages over rate control, yet a tre
4、nd toward lower mortality was observed in the rate-control arm of the AFFIRM study and did not differ in the other trials from the outcome with the rhythm control strategy. This might suggest that attempts to restore sinus rhythm with presently available antiarrhythmic drugs are obsolete. The RACE a
5、nd AFFIRM trials did not address AF in younger, symptomatic patients with little underlying heart disease, in whom restoration of sinus rhythm by cardioversion antiarrhythmic drugs or non-pharmacological interventions still must be considered a useful therapeutic approach. One may conclude from thes
6、e studies that rate control is a reasonable strategy in elderly patients with minimal symptoms related to AF. An effective method for maintaining sinus rhythm with fewer side effects would address a presently unmet need.,ACC/AHA/ESC Guidelines 2006,Results No difference in primary endpoint of CV dea
7、th between groups (Figure) Cardioversion 39% vs 8% Also no difference in total mortality (31.8% vs. 32.9%, p = 0.73), stroke (2.6% vs. 3.6%, p = 0.32), worsening heart failure (27.6% vs. 30.8%, p = 0.17), or composite (42.7% vs. 45.8%, p = 0.20) Higher hospitalization rates (46% vs 39% p=.006) and c
8、ost with rhythm control Bradyarrhythmias in rhythm control group Conclusions Among patients with heart failure and atrial fibrillation, use of rhythm control was not associated with differences in CV mortality compared with rate control Results were similar to AFFIRM trial, which also showed no impa
9、ct on mortality with rhythm control vs. rate control for management of atrial fibrillation,AF-CHF,%,Trial Design: AF-CHF was a randomized trial of rhythm control (n = 682) vs. rate control (n = 694) in patients with heart failure and atrial fibrillation. Rhythm control included use of electrical car
10、dioversion combined with antiarrhythmic drugs, including amiodarone as first-line therapy. Primary endpoint was CV death, with mean follow-up of 3 years.,Rhythm Control,Rate Control,CV Death (HR 1.06, p = 0.59),Bradyarrhythmia (p = 0.007),Presented at AHA Roy 2007,When and Why Acutely Cardiovert?,AF
11、 Begets AF,AF causes changes in atrial electrophysiology that promote AF maintenance,Wijffels Circulation 1995; 92: 1954-68,Lip GY Lancet 2007;370:604-18,Lip GY Lancet 2007; 370:604-18,Paroxysmal AF 48 hours (n=100) Amiodarone IV (3 gm) vs IV placebo,Cotter EHJ 1999; 20:1833-42,Paroxysmal AF 1 week
12、(n=100) Amiodarone IV (1.2 gm) vs placebo,Galve JACC 1996;27:1079-82,30/50 (60%) placebo patients converted,32/50 (64%) placebo patients converted,High Rates of Spontaneous Cardioversion for Recent-onset AF,Likelihood of Spontaneous Conversion of Atrial Fibrillation to Sinus Rhythm,Danias J Am Coll
13、Cardiol. 1998;31:588-92,356 pts with AF 72 h Symptoms of 24 h was only independent predictor of spontaneous conversion (OR: 1.8, p 0.0001), 24 h24 - 72 hTotal,29264356,73%45%68%,AF duration,n,Conversion,How often does spontaneous conversion occur over 8 weeks?,Klein A et al. N Engl J Med 2001;344:14
14、11-1420,Klein A et al. N Engl J Med 2001;344:1411-1420,Clinical Outcomes at 8 Weeks among Patients with Atrial Fibrillation of More Than 2 Days Duration,Spontaneous Conversion of Patients with AF Scheduled for Electrical Cardioversion An ACUTE Trial Ancillary Study,Tejan-Sie J Am Coll Cardiol 2007;4
15、2:1638-1643,Conversion According to Duration of Pre-existing AF,Daily Conversion According to Strategy,Spontaneous Conversion of Patients with AF Scheduled for Electrical Cardioversion An ACUTE Trial Ancillary Study,Tejan-Sie J Am Coll Cardiol 2007;42:1638-1643,Multivariable Model Predicting Spontan
16、eous Conversion,Conversion of Recent-Onset AF to Sinus Rhythm: Effects of Different Drug Protocols,Mean conversion time: Flecainide: 2.6 hrs Propafenone: 3.0 hrs,Conversion rates to sinus rhythm (%),* p 0.05 vs placebo * p 0.01 vs placebo,Boriani Pacing Clin Electrophysiol. 1998;21(11 Pt 2):2470-4,*
17、,*,417 hospitalized pts with AF onset 7 days,Cardioversion of atrial flutter and fibrillation after ibutilide infusion (67 y/o, 15 days duration, half with prior episode),Stambler Circulation. 1996;94:1613-1621,Predictors of Cardioversion with Ibutilide 201 patients treated,Zaqqa AJC 2000,Saliba J A
18、m Coll Cardiol 1999;34:2031-34,Biphasic shock Refractory to standard cardioversion (failed 2 attempts) 3 month in 55% SR in 46 (84%) of the 55 pts,Oral NEJM 1999;340:1849-54,100 consecutive patients 50 assigned conventional DC 50 pretreated with 1 mg ibutilide,Cardioversion success (%),How often doe
19、s spontaneous conversion occur after months of AF?,AF 7 to 360 days duration (110 average) CHF, recent MI, bradycardia excluded,Lancet. 2000;356:1789-94,Rhythm or rate control in atrial fibrillation: Pharmacological Intervention in Atrial Fibrillation (PIAF) Trial,Lancet. 2000;356:1789-94,Amiodarone
20、 group: 23% converted during amio load 76% had electrical cardioversion,Primary outcome: no difference,665 patients, 68 y/o Persistent AF, 76% 1yr On warfarin,Spontaneous Conversion 28 Days,N Engl J Med 2005;352:1861-72,Electrical More effective (90%) Quick One procedure with TEE Cardioversion itsel
21、f safe,Pharmacological Works well for recent onset, for atrial flutter Avoid sedation Less expensive Early maintenance enhanced by some drugs,Advantages and Disadvantages,What do the Guidelines Say?,Fuster V, Rydn LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with
22、atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibril
23、lation). Circulation. 2006;114:e257-e354.,Cardioversion of Atrial Fibrillation Clinical Issues,Cardioversion is common practice, albeit not well supported in trials that have been done Most new onset, and many paroxysmal atrial fibrillation episodes, are treated with cardioversion if they do not spontaneously convert in 24 to 48 hours While electrical cardioversion generally preferred, acute pharmacologic cardioversion has a role, that is not well defined,
