Curiosare tra le raccomandazioni. Fibrillazione atriale. Roberto Mantovan, MD, PhD Cardiologia Conegliano

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1 Curiosare tra le raccomandazioni delle nuove Linee Guida ESC Fibrillazione atriale Roberto Mantovan, MD, PhD Cardiologia

3 CRYptogenic STroke and underlying AtriaL Fibrillation (CRYSTAL AF): Long-Term Follow-Up Results Rod S. Passman, MD, Johannes Brachmann, MD, Ph.D. Carlos Morillo, MD, Tommaso Sanna, MD, Richard Bernstein, MD, Ph.D., Vincenzo Di Lazzaro, MD, Hans-Christoph Diener, MD, Ph.D., Marilyn Rymer, MD, Frank Beckers, Ph.D, Tyson Rogers, M.S., Paul Ziegler, M.S. for the Crystal AF Investigators

4 Objectives of CRYSTAL-AF Assess whether a long-term cardiac monitoring strategy with an insertable cardiac monitor (ICM) is superior to standard monitoring for the detection of AF in patients with cryptogenic stroke Determine the proportion of patients with cryptogenic stroke that are subsequently found to have AF Determine actions taken after patient is diagnosed with AF

5 Sanna T. N Engl J Med 2014; 370: Primary Endpoint: AF at 6 Months At 6 months AF was detected in 8.9% in the ICM group compared with 1.4% in controls (19 vs 3 pts.) Median time to AF detection: 41 d, 74% asymptomatic

6 Sanna T. N Engl J Med 2014; 370: CRYSTAL AF: Conclusion AF monitoring with an ICM is superior to conventional follow-up in cryptogenic stroke pts. Time ICM (%) Control (%) Hazard Ratio P 6 months months years AF was mostly asymptomatic and paroxysmal so unlikely to be detected by non continuous monitoring

8 By 3 months, subclinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients (10.1%). Subclinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation (hazard ratio, 5.56; 95% confidence interval [CI], 3.78 to 8.17; P<0.001) and of ischemic stroke or systemic embolism (hazard ratio, 2.49; 95% CI, 1.28 to 4.85; P = 0.007). n engl j med 366;2 nejm.org january 12, 2012

10 Hypertension Hypertension is a stroke risk factor in AF; uncontrolled high blood pressure enhances the risk of stroke and bleeding events and may lead to recurrent AF. Therefore, good blood pressure control should form an integral part of the management of AF patients

11 ESC AF guidelines 2010

12 Amiodarone: 400 mg Ibersartan: 150 o 300 mg sec PA Circulation 2002;106:

17 The intervention group showed a significantly greater reduction, compared with the control group, in weight (14.3 and 3.6 kg, respectively; P <.001) and in atrial fibrillation symptom burden scores (11.8 and 2.6 points, P <.001), symptom severity scores (8.4 and 1.7 points, P <.001), number of episodes (2.5 and no change, P =.01), and cumulative duration (692-minute decline and 419- minute increase, P =.002). JAMA. 2013;310(19):

20 Europace (2014) 16,

22 Europace (2009) 11,

European Heart Journal (2012) 33, 2692 2699 It consisted of nurse-led outpatient care steered by decision support software based on

(dedicated software CardioConsult AF) Visits to the nurse were scheduled to last 30 min.

26 European Heart Journal (2012) 33, It consisted of nurse-led outpatient care steered by decision support software based on the guidelines and supervised by a cardiologist. (dedicated software CardioConsult AF) Visits to the nurse were scheduled to last 30 min. Follow-up visits were planned at 3, 6, and 12 months, and every 6 months thereafter. Patients in the control group received usual care by a cardiologist in the outpatient clinic during visits scheduled to last 20 min for the first visit and 10 min for follow-up visits.

27 Esc guidelines 2016

28 Esc guidelines 2016

30 Comparable Primary Efficacy Endpoints of Stroke or Systemic Embolism ESC WG on Thrombosis - J Am Coll Cardiol 2012;59:

31 Comparable Primary Safety Endpoints of Major Bleeding ESC WG on Thrombosis - J Am Coll Cardiol 2012;59:

35 Antithrombotic therapy after acute coronary syndromes and percutaneous coronary intervention When a NOAC is used, the consensus recommendation is that the lowest dose effective for stroke prevention in AF should be considered. Dose reduction beyond the approved dosing tested in phase III trials is not currently recommended, and awaits assessment in ongoing controlled trials.

$) 124 patients with antiarrhythmic drug refractory atrial$ fibrillation with left atrial dilatation and hypertension (42

41 (Circulation. 2012;125:23-30.) 124 patients with antiarrhythmic drug refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients)

42 The Atrial Fibrillation Heart Team this Task Force proposes that decisions involving AF surgery or extensive AF ablation should be based on advice from an AF Heart Team An AF Heart Team should consist of a cardiologist with expertise in antiarrhythmic drug therapy, an interventional electrophysiologist, and a cardiac surgeon with expertise in appropriate patient selection, techniques, and technologies for interventional or surgical AF ablation (Figure 20)

45 GanesanJ Am Heart Assoc. 2013;2:e doi: /

46 ?

47 ?

48 ESC AF guidelines 2010

49 n engl j med 372;19 nejm.org May 7, 2015

50 Secondary Outcomes p= % 60% 58% Documented AF > 30 seconds after one or two procedures with or without AAD

51 Pazienti, sintomatici, refrattari ai farmaci, per l 80% in f.a. persistente da almeno 6 mesi Dopo un anno e mezzo 2 su 3 sono senza aritmia (per l 89% senza antiaritmici).. E circa il 95% sta nettamente meglio (per netta riduzione del burden aritmico) Abbiamo qualcosa di meglio da offrire al paziente?

52 Conclusioni Le nuove linee guida pongono una maggiore attenzione ai fattori di rischio della fibrillazione atriale (obesità, OSAS, sport esasperato) e sulla diagnostica della f.a. asintomatica Propongono modelli organizzativi (approccio integrato, AF heart Team) sicuramente auspicabili, ma di difficile realizzazione nella pratica clinica quotidiana

53 Conclusioni I NOA sono pienamente sdoganati dalla nuove linee guida ESC, anche se permangono delle complessità nella terapia di associazione con antiaggreganti Meno chiare sono invece le linee comportamentali sulla terapia interventistica, particolarmente nella f.a. persistente

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