atrial fibrillation and stroke prevention - Continuing Medical ...
atrial fibrillation and stroke prevention - Continuing Medical ... atrial fibrillation and stroke prevention - Continuing Medical ...
Essentials in Primary Care Conference Wednesday, July 31, 2013 Questions to answer • Would this patient benefit more from rate control or rhythm control with acute cardioversion or medical (anti-arrhythmic) conversion?-AFFIRM, AF-CHF • What is the target heart rate in a patient with asx or minimally symptomatic AF-(lenient vs strict rate control)?-RACE II AFFIRM Atrial Fibrillation Follow-up Investigation of Rhythm Management Primary Endpoint: All-Cause Mortality Mortality (%) Time (Y) 25 20 15 10 5 0 p = 0.08 •4080 pts, • mean age 70 yrs • 40% female •paroxysmal or persistent atrial fibrillation •All treated with coumadin Rhythm Rate Rhythm-guideline based anti-arrythmia Rx Rate-80 at rest,110 with exercise 0 1 2 3 4 5 Rate N 2027 1925 1825 1328 774 236 Rhythm N 2033 1932 1807 1316 780 255 AFFIRM Investigators. N Engl J Med. 2002;347:1825-33 Jan Basile, MD Atrial Fibrillation & Stroke Prevention
Essentials in Primary Care Conference Wednesday, July 31, 2013 The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) [EF < 35%, clinical HF] Trial: Results (n=1376;1 endpoint=time to death from CV causes Rhythm Control Rate Control p-value Cardiovascular Mortality 26.7 % 25.2 % NS Total Mortality 31.8 % 32.9 % NS Stroke 2.6 % 3.6 % NS Hospitalization 46 % 39 % 0.001 Worsening CHF 27.6 % 30.8 % NS Roy et al. N Engl J Med. 2008;358:2667-2677. RAte Control Efficacy in Permanent Atrial Fibrillation II (RACE II) • Since rate control is as good as rhythm control, then let’s test 311 patients randomized to lenient (resting HR < 110 BPM) vs 303 strict rate control (resting HR < 80 BPM, with exercise < 110 BPM) • Mean follow-up 2 years, max 3 years • BB alone (45%), CCB alone (6%), digoxin alone (6%), BB + dig (17%), BB + dilt/verap (3%), sotalol (5%), amiod (1.3%) Van Gelder IC, et al. RACE II trial. NEJM 2010;362:1363-73. Jan Basile, MD Atrial Fibrillation & Stroke Prevention
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Essentials in Primary Care Conference<br />
Wednesday, July 31, 2013<br />
Questions to answer<br />
• Would this patient benefit more<br />
from rate control or rhythm<br />
control with acute cardioversion<br />
or medical (anti-arrhythmic)<br />
conversion?-AFFIRM, AF-CHF<br />
• What is the target heart rate in a<br />
patient with asx or minimally<br />
symptomatic AF-(lenient vs strict<br />
rate control)?-RACE II<br />
AFFIRM<br />
Atrial Fibrillation Follow-up Investigation<br />
of Rhythm Management<br />
Primary Endpoint: All-Cause Mortality<br />
Mortality (%)<br />
Time (Y)<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
p = 0.08<br />
•4080 pts,<br />
• mean age 70 yrs<br />
• 40% female<br />
•paroxysmal or persistent <strong>atrial</strong> <strong>fibrillation</strong><br />
•All treated with coumadin<br />
Rhythm<br />
Rate<br />
Rhythm-guideline based anti-arrythmia Rx<br />
Rate-80 at rest,110 with exercise<br />
0 1 2 3 4 5<br />
Rate N 2027 1925 1825 1328 774 236<br />
Rhythm N 2033 1932 1807 1316 780 255<br />
AFFIRM Investigators. N Engl J Med. 2002;347:1825-33<br />
Jan Basile, MD<br />
Atrial Fibrillation & Stroke Prevention
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