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LAA occlusion boosts anticoagulants’ protection
ORLANDO – When patients with atrial fibrillation have a history of cardioembolic events despite optimal anticoagulant therapy, treatment with left atrial appendage occlusion can substantially improve protection against future events, according to a multicenter review of 22 patients.
During the 2 years prior to undergoing left atrial appendage (LAA) occlusion, the 22 atrial fibrillation (AF) patients studied had a total of 44 cardioembolic events despite receiving “optimal” treatment with an oral anticoagulant, including nine patients with one event, six patients with two events, five patients with three events, and two patients with four events each, Xavier Freixa, MD, said at the annual International AF Symposium. In contrast, during a median follow-up of 1.8 years after their procedure additional events occurred in just two patients – one with a stroke, the other with a transient ischemic attack, while the remaining 20 patients remained free of any additional events.
The analysis also revealed that the two patients who had cardioembolic events following their LAA occlusion had been withdrawn from oral anticoagulant treatment by their physicians, who had done this with a “false feeling of comfort,” said Dr. Freixa, an interventional cardiologist at the University Hospital Clinic of Barcelona. These two patients were among three patients maintained on dual-antiplatelet therapy rather than on an oral anticoagulant following LAA occlusion. The remaining 19 patients had remained on either warfarin, a novel oral anticoagulant, or both.
The study included patients from eight Spanish centers who underwent LAA occlusion during June 2009–June 2017, and included 14 with nonvalvular AF and 8 with valvular AF who had all undergone prior valve surgery. None of the 22 patients had a contraindication for treatment with an oral anticoagulant. They averaged about 69 years of age. Prior to their procedure, 18 had at least one stroke or transient ischemic attack, and the remaining 4 patients had at least one systemic embolism. Nineteen patients underwent occlusion with either an Amplatzer Cardiac Plug or Amplatzer Amulet device, two received a Watchman device, and one patient received a LAmbre device. All of the closure procedures were successful, with no complications.
“I think any device will do well for these patients as long as we occlude the LAA,” Dr. Freixa said.
[email protected]
On Twitter @mitchelzoler
SOURCE: Freixa X et al. AF Symposium 2018 Abstract 1821.
ORLANDO – When patients with atrial fibrillation have a history of cardioembolic events despite optimal anticoagulant therapy, treatment with left atrial appendage occlusion can substantially improve protection against future events, according to a multicenter review of 22 patients.
During the 2 years prior to undergoing left atrial appendage (LAA) occlusion, the 22 atrial fibrillation (AF) patients studied had a total of 44 cardioembolic events despite receiving “optimal” treatment with an oral anticoagulant, including nine patients with one event, six patients with two events, five patients with three events, and two patients with four events each, Xavier Freixa, MD, said at the annual International AF Symposium. In contrast, during a median follow-up of 1.8 years after their procedure additional events occurred in just two patients – one with a stroke, the other with a transient ischemic attack, while the remaining 20 patients remained free of any additional events.
The analysis also revealed that the two patients who had cardioembolic events following their LAA occlusion had been withdrawn from oral anticoagulant treatment by their physicians, who had done this with a “false feeling of comfort,” said Dr. Freixa, an interventional cardiologist at the University Hospital Clinic of Barcelona. These two patients were among three patients maintained on dual-antiplatelet therapy rather than on an oral anticoagulant following LAA occlusion. The remaining 19 patients had remained on either warfarin, a novel oral anticoagulant, or both.
The study included patients from eight Spanish centers who underwent LAA occlusion during June 2009–June 2017, and included 14 with nonvalvular AF and 8 with valvular AF who had all undergone prior valve surgery. None of the 22 patients had a contraindication for treatment with an oral anticoagulant. They averaged about 69 years of age. Prior to their procedure, 18 had at least one stroke or transient ischemic attack, and the remaining 4 patients had at least one systemic embolism. Nineteen patients underwent occlusion with either an Amplatzer Cardiac Plug or Amplatzer Amulet device, two received a Watchman device, and one patient received a LAmbre device. All of the closure procedures were successful, with no complications.
“I think any device will do well for these patients as long as we occlude the LAA,” Dr. Freixa said.
[email protected]
On Twitter @mitchelzoler
SOURCE: Freixa X et al. AF Symposium 2018 Abstract 1821.
ORLANDO – When patients with atrial fibrillation have a history of cardioembolic events despite optimal anticoagulant therapy, treatment with left atrial appendage occlusion can substantially improve protection against future events, according to a multicenter review of 22 patients.
During the 2 years prior to undergoing left atrial appendage (LAA) occlusion, the 22 atrial fibrillation (AF) patients studied had a total of 44 cardioembolic events despite receiving “optimal” treatment with an oral anticoagulant, including nine patients with one event, six patients with two events, five patients with three events, and two patients with four events each, Xavier Freixa, MD, said at the annual International AF Symposium. In contrast, during a median follow-up of 1.8 years after their procedure additional events occurred in just two patients – one with a stroke, the other with a transient ischemic attack, while the remaining 20 patients remained free of any additional events.
The analysis also revealed that the two patients who had cardioembolic events following their LAA occlusion had been withdrawn from oral anticoagulant treatment by their physicians, who had done this with a “false feeling of comfort,” said Dr. Freixa, an interventional cardiologist at the University Hospital Clinic of Barcelona. These two patients were among three patients maintained on dual-antiplatelet therapy rather than on an oral anticoagulant following LAA occlusion. The remaining 19 patients had remained on either warfarin, a novel oral anticoagulant, or both.
The study included patients from eight Spanish centers who underwent LAA occlusion during June 2009–June 2017, and included 14 with nonvalvular AF and 8 with valvular AF who had all undergone prior valve surgery. None of the 22 patients had a contraindication for treatment with an oral anticoagulant. They averaged about 69 years of age. Prior to their procedure, 18 had at least one stroke or transient ischemic attack, and the remaining 4 patients had at least one systemic embolism. Nineteen patients underwent occlusion with either an Amplatzer Cardiac Plug or Amplatzer Amulet device, two received a Watchman device, and one patient received a LAmbre device. All of the closure procedures were successful, with no complications.
“I think any device will do well for these patients as long as we occlude the LAA,” Dr. Freixa said.
[email protected]
On Twitter @mitchelzoler
SOURCE: Freixa X et al. AF Symposium 2018 Abstract 1821.
REPORTING FROM THE AF SYMPOSIUM 2018
Key clinical point:
Major finding: Two of 22 patients had a cardioembolic event after left atrial appendage occlusion.
Study details: Review of 22 patients at eight Spanish centers with atrial fibrillation and a history of cardioembolic events despite oral anticoagulation.
Disclosures: Dr. Freixa has been a proctor for Abbott Medical.
Source: Freixa X et al. AF Symposium 2018 Abstract 1821.
Atrial fibrosis weighed as key arrhythmia, stroke trigger
ORLANDO – , particularly strokes, and has also become the target for ablative strategies by some operators for more effective rhythm control in patients with atrial fibrillation.
“A strong and graded association exists between the severity of left atrial fibrosis severity and major cardiovascular adverse events, primarily due to stroke, transient ischemic attack, and heart failure, Nassir F. Marrouche, MD, said at the annual International AF Symposium.
Atrial fibrosis is quantified noninvasively by Dr. Marrouche and his associates with late gadolinium enhancement MRI. They published results of a retrospective study in 2017 showing that, during follow-up of 1,228 patients from their center with atrial fibrillation, the 5% of patients who had the highest level of left atrial fibrosis – 30% or more of left atrial tissue – had a significantly increased rate of cardiovascular events during follow-up, compared with the 35% of studied patients with fibrosis constituting less than 10% of their left atrium. The remaining 60% of studied patients had fibrotic tissue that formed 10%-29% of their total left atrial area.
This relationship was strongest when the analysis focused exclusively on the incidence of strokes or transient ischemic attacks. These events occurred nearly fourfold more often among patients with the highest amount of fibrosis, compared with those with the least (J Amer Coll Cardiol. 2017 Sep;70[11]:311-21).
Given that the finding came from a retrospective, single-center study, the clinical implication of fibrosis remains too uncertain to apply to current routine practice. But Dr. Marrouche strongly suspects that fibrotic tissue in the left atrium serves as a potent trigger of thrombosis.
“We think that even patients with a CHA2DS2-VASc score of zero who have a high level of fibrosis may need treatment with an anticoagulant, but we need a prospective study” to validate this, Dr. Marrouche said.
Another area for further research is to explore agents that may be able to prevent or reverse fibrosis in the left atrium. One candidate class of drugs are the angiotensin-converting enzyme inhibitors, he said in an interview.
Atrial fibrosis can have a variety of causes, including hypertension, inflammation, genetics, frequent high-intensity exercise, or other histories that produce regular intervals of extreme atrial stretch, he noted.
Dr. Marrouche is leading a multicenter trial that will test the efficacy of an ablation method for patients with atrial fibrillation tailored to isolating heavily fibrotic regions of the atria. The Efficacy of Delayed Enhancement MRI-Guided Ablation vs. Conventional Catheter Ablation of Atrial Fibrillation (DECAAFII) trial is comparing ablation aimed at fibrotic regions against conventional ablation in about 900 patients. Results are expected in another 2-3 years.
Although the usefulness of ablation aimed at isolating areas of fibrosis in the atrium remains unproven, this approach has already been embraced by some operators, including Hans Kottkamp, MD, a professor and electrophysiologist at Hirslanden Hospital in Zurich.
“Fibrosis is the fundamental histologic finding and the key pathophysiologic player in atrial fibrillation,” Dr. Kottkamp said in a separate talk at the meeting. “We suggest doing ablation based on the substrate, and not based on whether the atrial fibrillation is paroxysmal or persistent.” His group uses voltage mapping instead of MRI as their tool for quantifying the amount of fibrosis and pinpointing its location.
“The fibrosis is usually regionalized; it’s not everywhere” in the left atrium, Dr. Kottkamp noted, and the location is very individualized. “You need to look for it in each patient.”
In his experience, about 20% of patients with paroxysmal AF have enough atrial fibrosis to warrant using BIFA along with pulmonary vein isolation. “Among patients with persistent AF, the percentage with significant fibrosis rises to about two-thirds,” Dr. Kottkamp said in an interview. Combining BIFA with pulmonary vein isolation in these patients with higher fibrosis substantially boosts procedural success.
In a recent report, Dr. Kottkamp and his associates presented their experience using BIFA on 92 patients with AF and fibrotic atrial cardiomyopathy. The outcomes showed a relatively high level of success in resolving the AF after an average follow-up of 16 months, with a 69% success rate after a single procedure and an 83% success rate when selected patients received a second BIFA.
Overall, each patient in the series received an average of 1.2 BIFA ablations (J Cardiovasc Electrophysiol. 2017 Sep;28[9]:971-83).
Currently, a limited number of other groups uses BIFA or a similar fibrosis-based ablation approach, and these strategies have not yet undergone prospective assessment in a multicenter study. Despite that, Dr. Kottkamp said he was “confident it will become standard of care.”
Dr. Marrouche has been a consultant to Abbott, Biosense Webster, Biotronik, Boston Scientific, Cardiac Design, Marreck, Medtronic, Preventice, VytronUS, and Wavelet Health, and he has received research support from Abbott, Biosense Webster, Biotronik, Boston Scientific, GE Sciences, and VytronUS. Dr. Kottkamp has been a consultant to Biosense Webster and has been a consultant to and has an equity interest in Kardium.
ORLANDO – , particularly strokes, and has also become the target for ablative strategies by some operators for more effective rhythm control in patients with atrial fibrillation.
“A strong and graded association exists between the severity of left atrial fibrosis severity and major cardiovascular adverse events, primarily due to stroke, transient ischemic attack, and heart failure, Nassir F. Marrouche, MD, said at the annual International AF Symposium.
Atrial fibrosis is quantified noninvasively by Dr. Marrouche and his associates with late gadolinium enhancement MRI. They published results of a retrospective study in 2017 showing that, during follow-up of 1,228 patients from their center with atrial fibrillation, the 5% of patients who had the highest level of left atrial fibrosis – 30% or more of left atrial tissue – had a significantly increased rate of cardiovascular events during follow-up, compared with the 35% of studied patients with fibrosis constituting less than 10% of their left atrium. The remaining 60% of studied patients had fibrotic tissue that formed 10%-29% of their total left atrial area.
This relationship was strongest when the analysis focused exclusively on the incidence of strokes or transient ischemic attacks. These events occurred nearly fourfold more often among patients with the highest amount of fibrosis, compared with those with the least (J Amer Coll Cardiol. 2017 Sep;70[11]:311-21).
Given that the finding came from a retrospective, single-center study, the clinical implication of fibrosis remains too uncertain to apply to current routine practice. But Dr. Marrouche strongly suspects that fibrotic tissue in the left atrium serves as a potent trigger of thrombosis.
“We think that even patients with a CHA2DS2-VASc score of zero who have a high level of fibrosis may need treatment with an anticoagulant, but we need a prospective study” to validate this, Dr. Marrouche said.
Another area for further research is to explore agents that may be able to prevent or reverse fibrosis in the left atrium. One candidate class of drugs are the angiotensin-converting enzyme inhibitors, he said in an interview.
Atrial fibrosis can have a variety of causes, including hypertension, inflammation, genetics, frequent high-intensity exercise, or other histories that produce regular intervals of extreme atrial stretch, he noted.
Dr. Marrouche is leading a multicenter trial that will test the efficacy of an ablation method for patients with atrial fibrillation tailored to isolating heavily fibrotic regions of the atria. The Efficacy of Delayed Enhancement MRI-Guided Ablation vs. Conventional Catheter Ablation of Atrial Fibrillation (DECAAFII) trial is comparing ablation aimed at fibrotic regions against conventional ablation in about 900 patients. Results are expected in another 2-3 years.
Although the usefulness of ablation aimed at isolating areas of fibrosis in the atrium remains unproven, this approach has already been embraced by some operators, including Hans Kottkamp, MD, a professor and electrophysiologist at Hirslanden Hospital in Zurich.
“Fibrosis is the fundamental histologic finding and the key pathophysiologic player in atrial fibrillation,” Dr. Kottkamp said in a separate talk at the meeting. “We suggest doing ablation based on the substrate, and not based on whether the atrial fibrillation is paroxysmal or persistent.” His group uses voltage mapping instead of MRI as their tool for quantifying the amount of fibrosis and pinpointing its location.
“The fibrosis is usually regionalized; it’s not everywhere” in the left atrium, Dr. Kottkamp noted, and the location is very individualized. “You need to look for it in each patient.”
In his experience, about 20% of patients with paroxysmal AF have enough atrial fibrosis to warrant using BIFA along with pulmonary vein isolation. “Among patients with persistent AF, the percentage with significant fibrosis rises to about two-thirds,” Dr. Kottkamp said in an interview. Combining BIFA with pulmonary vein isolation in these patients with higher fibrosis substantially boosts procedural success.
In a recent report, Dr. Kottkamp and his associates presented their experience using BIFA on 92 patients with AF and fibrotic atrial cardiomyopathy. The outcomes showed a relatively high level of success in resolving the AF after an average follow-up of 16 months, with a 69% success rate after a single procedure and an 83% success rate when selected patients received a second BIFA.
Overall, each patient in the series received an average of 1.2 BIFA ablations (J Cardiovasc Electrophysiol. 2017 Sep;28[9]:971-83).
Currently, a limited number of other groups uses BIFA or a similar fibrosis-based ablation approach, and these strategies have not yet undergone prospective assessment in a multicenter study. Despite that, Dr. Kottkamp said he was “confident it will become standard of care.”
Dr. Marrouche has been a consultant to Abbott, Biosense Webster, Biotronik, Boston Scientific, Cardiac Design, Marreck, Medtronic, Preventice, VytronUS, and Wavelet Health, and he has received research support from Abbott, Biosense Webster, Biotronik, Boston Scientific, GE Sciences, and VytronUS. Dr. Kottkamp has been a consultant to Biosense Webster and has been a consultant to and has an equity interest in Kardium.
ORLANDO – , particularly strokes, and has also become the target for ablative strategies by some operators for more effective rhythm control in patients with atrial fibrillation.
“A strong and graded association exists between the severity of left atrial fibrosis severity and major cardiovascular adverse events, primarily due to stroke, transient ischemic attack, and heart failure, Nassir F. Marrouche, MD, said at the annual International AF Symposium.
Atrial fibrosis is quantified noninvasively by Dr. Marrouche and his associates with late gadolinium enhancement MRI. They published results of a retrospective study in 2017 showing that, during follow-up of 1,228 patients from their center with atrial fibrillation, the 5% of patients who had the highest level of left atrial fibrosis – 30% or more of left atrial tissue – had a significantly increased rate of cardiovascular events during follow-up, compared with the 35% of studied patients with fibrosis constituting less than 10% of their left atrium. The remaining 60% of studied patients had fibrotic tissue that formed 10%-29% of their total left atrial area.
This relationship was strongest when the analysis focused exclusively on the incidence of strokes or transient ischemic attacks. These events occurred nearly fourfold more often among patients with the highest amount of fibrosis, compared with those with the least (J Amer Coll Cardiol. 2017 Sep;70[11]:311-21).
Given that the finding came from a retrospective, single-center study, the clinical implication of fibrosis remains too uncertain to apply to current routine practice. But Dr. Marrouche strongly suspects that fibrotic tissue in the left atrium serves as a potent trigger of thrombosis.
“We think that even patients with a CHA2DS2-VASc score of zero who have a high level of fibrosis may need treatment with an anticoagulant, but we need a prospective study” to validate this, Dr. Marrouche said.
Another area for further research is to explore agents that may be able to prevent or reverse fibrosis in the left atrium. One candidate class of drugs are the angiotensin-converting enzyme inhibitors, he said in an interview.
Atrial fibrosis can have a variety of causes, including hypertension, inflammation, genetics, frequent high-intensity exercise, or other histories that produce regular intervals of extreme atrial stretch, he noted.
Dr. Marrouche is leading a multicenter trial that will test the efficacy of an ablation method for patients with atrial fibrillation tailored to isolating heavily fibrotic regions of the atria. The Efficacy of Delayed Enhancement MRI-Guided Ablation vs. Conventional Catheter Ablation of Atrial Fibrillation (DECAAFII) trial is comparing ablation aimed at fibrotic regions against conventional ablation in about 900 patients. Results are expected in another 2-3 years.
Although the usefulness of ablation aimed at isolating areas of fibrosis in the atrium remains unproven, this approach has already been embraced by some operators, including Hans Kottkamp, MD, a professor and electrophysiologist at Hirslanden Hospital in Zurich.
“Fibrosis is the fundamental histologic finding and the key pathophysiologic player in atrial fibrillation,” Dr. Kottkamp said in a separate talk at the meeting. “We suggest doing ablation based on the substrate, and not based on whether the atrial fibrillation is paroxysmal or persistent.” His group uses voltage mapping instead of MRI as their tool for quantifying the amount of fibrosis and pinpointing its location.
“The fibrosis is usually regionalized; it’s not everywhere” in the left atrium, Dr. Kottkamp noted, and the location is very individualized. “You need to look for it in each patient.”
In his experience, about 20% of patients with paroxysmal AF have enough atrial fibrosis to warrant using BIFA along with pulmonary vein isolation. “Among patients with persistent AF, the percentage with significant fibrosis rises to about two-thirds,” Dr. Kottkamp said in an interview. Combining BIFA with pulmonary vein isolation in these patients with higher fibrosis substantially boosts procedural success.
In a recent report, Dr. Kottkamp and his associates presented their experience using BIFA on 92 patients with AF and fibrotic atrial cardiomyopathy. The outcomes showed a relatively high level of success in resolving the AF after an average follow-up of 16 months, with a 69% success rate after a single procedure and an 83% success rate when selected patients received a second BIFA.
Overall, each patient in the series received an average of 1.2 BIFA ablations (J Cardiovasc Electrophysiol. 2017 Sep;28[9]:971-83).
Currently, a limited number of other groups uses BIFA or a similar fibrosis-based ablation approach, and these strategies have not yet undergone prospective assessment in a multicenter study. Despite that, Dr. Kottkamp said he was “confident it will become standard of care.”
Dr. Marrouche has been a consultant to Abbott, Biosense Webster, Biotronik, Boston Scientific, Cardiac Design, Marreck, Medtronic, Preventice, VytronUS, and Wavelet Health, and he has received research support from Abbott, Biosense Webster, Biotronik, Boston Scientific, GE Sciences, and VytronUS. Dr. Kottkamp has been a consultant to Biosense Webster and has been a consultant to and has an equity interest in Kardium.
EXPERT ANALYSIS FROM AF SYMPOSIUM 2018
HRS: Consider ablation for asymptomatic atrial fib
ORLANDO – When the Heart Rhythm Society and several collaborating groups published in October 2017 the first revised consensus statement on atrial fibrillation ablation in 5 years, the document included a novel and perhaps unexpected suggestion: Ablation for asymptomatic atrial fibrillation “may be considered.”
This was “the first time” any group of experts suggested an indication potentially existed for ablating asymptomatic atrial fibrillation (AF), Hugh Calkins, MD, said at the annual International AF Symposium.
“You might say ‘are you out of your mind recommending ablation for asymptomatic AF?’ ” conceded Dr. Calkins, professor of medicine and director of the arrhythmia service at Johns Hopkins Medicine in Baltimore. But Dr. Calkins quickly added that this was a “soft” recommendation by being in the “may be considered” category, and he also noted that it received broad support from about 90% of the members of the statement’s 60-member writing group (Heart Rhythm. 2017 Oct;14[10]:e445-e494).
In addition, he personally believed that an amber light for this strategy made a lot of sense.
He also acknowledged that this recommendation is sort of buried in the text of the consensus statement and does not appear in any summary diagram “because the reviewers wanted us to hide it. Only those who are passionate about ablation know about it.
“Our goal was not to send a message that this is for everyone. It’s for very select patients and for very select operators after a very careful discussion” of the risks and potential benefits from performing the procedure on a truly asymptomatic patient.
The ideal candidate for this approach would be a relatively young patient, say someone in their 50s, who is identified as having AF incidentally, such as someone with an irregular pulse that’s found during a routine examination that leads to an ECG and definitive identification of AF despite the patient’s complete denial of having symptoms.
The next step, Dr. Calkins suggested, would be to treat the patient with an antiarrhythmic drug, such as amiodarone or flecainide, and with cardioversion and see whether this stops the AF and makes the patient feel better. If the patient reports improvement, it suggests the AF really is symptomatic and management could then proceed as with any case of symptomatic AF. But if the patient perceives no change and the AF then recurs in a persistent presentation despite drug treatment, the cardiologist could then discuss with the patient the pros and cons of an ablative procedure.
The pros for immediate ablation are that, when left unablated, the patient will face a substantially increased lifetime risk for stroke, dementia, and new onset heart failure, and after 2-3 years of continued persistent AF the left atrium would remodel and become much less likely to respond to ablation with little prospect for the patient ever returning to a normal sinus rhythm. “It’s either a rhythm control strategy now, or we’ll leave you in AF for the rest of your life,” Dr. Calkins explained. “If I were 50 years old and had asymptomatic AF, there’s no way I’d want to have AF for the rest of my life.” The risks from ablation are that the procedure has about a 68% success rate and about a 1% rate of complications.
“A patient with asymptomatic paroxysmal AF doesn’t have much to lose by waiting and seeing whether symptoms develop, but for the patient with persistent AF there is a penalty for allowing continuous AF, because after 2-3 years you won’t be able to successfully ablate it. In the past, we left patients with asymptomatic AF that way for the rest of their life, but now we know that if patients remain in AF over time, they will lose the option to have it ablated, and their risk of stroke, dementia, and heart failure will increase.”Dr. Calkins has been a consultant or adviser to or received honoraria from Abbott, AtriCure, Boehringer Ingelheim, Boston Scientific, iRhythm, Medtronic, Pfizer, St. Jude, and Toray, He has also received research funding from Boston Scientific and Medtronic.
This article was updated 2/9/18.
ORLANDO – When the Heart Rhythm Society and several collaborating groups published in October 2017 the first revised consensus statement on atrial fibrillation ablation in 5 years, the document included a novel and perhaps unexpected suggestion: Ablation for asymptomatic atrial fibrillation “may be considered.”
This was “the first time” any group of experts suggested an indication potentially existed for ablating asymptomatic atrial fibrillation (AF), Hugh Calkins, MD, said at the annual International AF Symposium.
“You might say ‘are you out of your mind recommending ablation for asymptomatic AF?’ ” conceded Dr. Calkins, professor of medicine and director of the arrhythmia service at Johns Hopkins Medicine in Baltimore. But Dr. Calkins quickly added that this was a “soft” recommendation by being in the “may be considered” category, and he also noted that it received broad support from about 90% of the members of the statement’s 60-member writing group (Heart Rhythm. 2017 Oct;14[10]:e445-e494).
In addition, he personally believed that an amber light for this strategy made a lot of sense.
He also acknowledged that this recommendation is sort of buried in the text of the consensus statement and does not appear in any summary diagram “because the reviewers wanted us to hide it. Only those who are passionate about ablation know about it.
“Our goal was not to send a message that this is for everyone. It’s for very select patients and for very select operators after a very careful discussion” of the risks and potential benefits from performing the procedure on a truly asymptomatic patient.
The ideal candidate for this approach would be a relatively young patient, say someone in their 50s, who is identified as having AF incidentally, such as someone with an irregular pulse that’s found during a routine examination that leads to an ECG and definitive identification of AF despite the patient’s complete denial of having symptoms.
The next step, Dr. Calkins suggested, would be to treat the patient with an antiarrhythmic drug, such as amiodarone or flecainide, and with cardioversion and see whether this stops the AF and makes the patient feel better. If the patient reports improvement, it suggests the AF really is symptomatic and management could then proceed as with any case of symptomatic AF. But if the patient perceives no change and the AF then recurs in a persistent presentation despite drug treatment, the cardiologist could then discuss with the patient the pros and cons of an ablative procedure.
The pros for immediate ablation are that, when left unablated, the patient will face a substantially increased lifetime risk for stroke, dementia, and new onset heart failure, and after 2-3 years of continued persistent AF the left atrium would remodel and become much less likely to respond to ablation with little prospect for the patient ever returning to a normal sinus rhythm. “It’s either a rhythm control strategy now, or we’ll leave you in AF for the rest of your life,” Dr. Calkins explained. “If I were 50 years old and had asymptomatic AF, there’s no way I’d want to have AF for the rest of my life.” The risks from ablation are that the procedure has about a 68% success rate and about a 1% rate of complications.
“A patient with asymptomatic paroxysmal AF doesn’t have much to lose by waiting and seeing whether symptoms develop, but for the patient with persistent AF there is a penalty for allowing continuous AF, because after 2-3 years you won’t be able to successfully ablate it. In the past, we left patients with asymptomatic AF that way for the rest of their life, but now we know that if patients remain in AF over time, they will lose the option to have it ablated, and their risk of stroke, dementia, and heart failure will increase.”Dr. Calkins has been a consultant or adviser to or received honoraria from Abbott, AtriCure, Boehringer Ingelheim, Boston Scientific, iRhythm, Medtronic, Pfizer, St. Jude, and Toray, He has also received research funding from Boston Scientific and Medtronic.
This article was updated 2/9/18.
ORLANDO – When the Heart Rhythm Society and several collaborating groups published in October 2017 the first revised consensus statement on atrial fibrillation ablation in 5 years, the document included a novel and perhaps unexpected suggestion: Ablation for asymptomatic atrial fibrillation “may be considered.”
This was “the first time” any group of experts suggested an indication potentially existed for ablating asymptomatic atrial fibrillation (AF), Hugh Calkins, MD, said at the annual International AF Symposium.
“You might say ‘are you out of your mind recommending ablation for asymptomatic AF?’ ” conceded Dr. Calkins, professor of medicine and director of the arrhythmia service at Johns Hopkins Medicine in Baltimore. But Dr. Calkins quickly added that this was a “soft” recommendation by being in the “may be considered” category, and he also noted that it received broad support from about 90% of the members of the statement’s 60-member writing group (Heart Rhythm. 2017 Oct;14[10]:e445-e494).
In addition, he personally believed that an amber light for this strategy made a lot of sense.
He also acknowledged that this recommendation is sort of buried in the text of the consensus statement and does not appear in any summary diagram “because the reviewers wanted us to hide it. Only those who are passionate about ablation know about it.
“Our goal was not to send a message that this is for everyone. It’s for very select patients and for very select operators after a very careful discussion” of the risks and potential benefits from performing the procedure on a truly asymptomatic patient.
The ideal candidate for this approach would be a relatively young patient, say someone in their 50s, who is identified as having AF incidentally, such as someone with an irregular pulse that’s found during a routine examination that leads to an ECG and definitive identification of AF despite the patient’s complete denial of having symptoms.
The next step, Dr. Calkins suggested, would be to treat the patient with an antiarrhythmic drug, such as amiodarone or flecainide, and with cardioversion and see whether this stops the AF and makes the patient feel better. If the patient reports improvement, it suggests the AF really is symptomatic and management could then proceed as with any case of symptomatic AF. But if the patient perceives no change and the AF then recurs in a persistent presentation despite drug treatment, the cardiologist could then discuss with the patient the pros and cons of an ablative procedure.
The pros for immediate ablation are that, when left unablated, the patient will face a substantially increased lifetime risk for stroke, dementia, and new onset heart failure, and after 2-3 years of continued persistent AF the left atrium would remodel and become much less likely to respond to ablation with little prospect for the patient ever returning to a normal sinus rhythm. “It’s either a rhythm control strategy now, or we’ll leave you in AF for the rest of your life,” Dr. Calkins explained. “If I were 50 years old and had asymptomatic AF, there’s no way I’d want to have AF for the rest of my life.” The risks from ablation are that the procedure has about a 68% success rate and about a 1% rate of complications.
“A patient with asymptomatic paroxysmal AF doesn’t have much to lose by waiting and seeing whether symptoms develop, but for the patient with persistent AF there is a penalty for allowing continuous AF, because after 2-3 years you won’t be able to successfully ablate it. In the past, we left patients with asymptomatic AF that way for the rest of their life, but now we know that if patients remain in AF over time, they will lose the option to have it ablated, and their risk of stroke, dementia, and heart failure will increase.”Dr. Calkins has been a consultant or adviser to or received honoraria from Abbott, AtriCure, Boehringer Ingelheim, Boston Scientific, iRhythm, Medtronic, Pfizer, St. Jude, and Toray, He has also received research funding from Boston Scientific and Medtronic.
This article was updated 2/9/18.
EXPERT ANALYSIS FROM THE AF SYMPOSIUM 2018
VIDEO: Anticoagulant underprescribing common, jeopardizing atrial fib patients
ORLANDO – A high fraction of U.S. patients with atrial fibrillation receive an inappropriately low dosage of an anticoagulant for stroke prevention, often in a misguided attempt to avoid potential bleeding complications.
When physicians “reduce the dose to prevent a bleed they increase the risk for an ischemic stroke,” Elaine M. Hylek, MD, said in a video interview during the annual International AF Symposium.
Recent data on actual anticoagulant dosages prescribed to U.S. patients with atrial fibrillation show that “an unexpectedly high proportion of prescriptions for apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are given at lower doses,” Dr. Hylek noted at the meeting. The lower-dose formulations with U.S. marketing are only appropriate for patients on apixaban with at least two of the following: serum creatinine 1.5 mg/dL or higher, age 80 years or older, and weight 60 kg or less; patients on dabigatran with moderate renal impairment or treated with dronedarone or systemic ketoconazole; or patients on rivaroxaban with a creatinine clearance of 15-50 mL/min.
For example, in the pivotal trial for apixaban only 5% of atrial fibrillation patients qualified for the lower dosage, yet recent data have shown that, in actual U.S. practice roughly a quarter of patients were on this lower dosage, said Dr. Hylek, professor of medicine at Boston University and director of the thrombosis and anticoagulation service at Boston Medical Center (Curr Med Res Opin. 2016 July;32[7]:1277-79). A second recent report showed that among U.S. patients with atrial fibrillation hospitalized for an ischemic stroke 84% had received inadequate anticoagulation with either subtherapeutic dosages of anticoagulant or no anticoagulant at all (JAMA. 2017 Mar 14;317[10]:1057-67).
Another manifestation of the underprescribing problem are patients with atrial fibrillation treated with aspirin only, an approach proven ineffective for preventing ischemic strokes in these patients, Dr. Hylek said.
Dr. Hylek has been an advisor to or has received honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Doasense, Janssen, Medtronic, Pfizer, and Portola, and she has received research funding from Boehringer Ingelheim, Bristol-Myers Squibb, and Janssen.
[email protected]
On Twitter @mitchelzoler
ORLANDO – A high fraction of U.S. patients with atrial fibrillation receive an inappropriately low dosage of an anticoagulant for stroke prevention, often in a misguided attempt to avoid potential bleeding complications.
When physicians “reduce the dose to prevent a bleed they increase the risk for an ischemic stroke,” Elaine M. Hylek, MD, said in a video interview during the annual International AF Symposium.
Recent data on actual anticoagulant dosages prescribed to U.S. patients with atrial fibrillation show that “an unexpectedly high proportion of prescriptions for apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are given at lower doses,” Dr. Hylek noted at the meeting. The lower-dose formulations with U.S. marketing are only appropriate for patients on apixaban with at least two of the following: serum creatinine 1.5 mg/dL or higher, age 80 years or older, and weight 60 kg or less; patients on dabigatran with moderate renal impairment or treated with dronedarone or systemic ketoconazole; or patients on rivaroxaban with a creatinine clearance of 15-50 mL/min.
For example, in the pivotal trial for apixaban only 5% of atrial fibrillation patients qualified for the lower dosage, yet recent data have shown that, in actual U.S. practice roughly a quarter of patients were on this lower dosage, said Dr. Hylek, professor of medicine at Boston University and director of the thrombosis and anticoagulation service at Boston Medical Center (Curr Med Res Opin. 2016 July;32[7]:1277-79). A second recent report showed that among U.S. patients with atrial fibrillation hospitalized for an ischemic stroke 84% had received inadequate anticoagulation with either subtherapeutic dosages of anticoagulant or no anticoagulant at all (JAMA. 2017 Mar 14;317[10]:1057-67).
Another manifestation of the underprescribing problem are patients with atrial fibrillation treated with aspirin only, an approach proven ineffective for preventing ischemic strokes in these patients, Dr. Hylek said.
Dr. Hylek has been an advisor to or has received honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Doasense, Janssen, Medtronic, Pfizer, and Portola, and she has received research funding from Boehringer Ingelheim, Bristol-Myers Squibb, and Janssen.
[email protected]
On Twitter @mitchelzoler
ORLANDO – A high fraction of U.S. patients with atrial fibrillation receive an inappropriately low dosage of an anticoagulant for stroke prevention, often in a misguided attempt to avoid potential bleeding complications.
When physicians “reduce the dose to prevent a bleed they increase the risk for an ischemic stroke,” Elaine M. Hylek, MD, said in a video interview during the annual International AF Symposium.
Recent data on actual anticoagulant dosages prescribed to U.S. patients with atrial fibrillation show that “an unexpectedly high proportion of prescriptions for apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are given at lower doses,” Dr. Hylek noted at the meeting. The lower-dose formulations with U.S. marketing are only appropriate for patients on apixaban with at least two of the following: serum creatinine 1.5 mg/dL or higher, age 80 years or older, and weight 60 kg or less; patients on dabigatran with moderate renal impairment or treated with dronedarone or systemic ketoconazole; or patients on rivaroxaban with a creatinine clearance of 15-50 mL/min.
For example, in the pivotal trial for apixaban only 5% of atrial fibrillation patients qualified for the lower dosage, yet recent data have shown that, in actual U.S. practice roughly a quarter of patients were on this lower dosage, said Dr. Hylek, professor of medicine at Boston University and director of the thrombosis and anticoagulation service at Boston Medical Center (Curr Med Res Opin. 2016 July;32[7]:1277-79). A second recent report showed that among U.S. patients with atrial fibrillation hospitalized for an ischemic stroke 84% had received inadequate anticoagulation with either subtherapeutic dosages of anticoagulant or no anticoagulant at all (JAMA. 2017 Mar 14;317[10]:1057-67).
Another manifestation of the underprescribing problem are patients with atrial fibrillation treated with aspirin only, an approach proven ineffective for preventing ischemic strokes in these patients, Dr. Hylek said.
Dr. Hylek has been an advisor to or has received honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Doasense, Janssen, Medtronic, Pfizer, and Portola, and she has received research funding from Boehringer Ingelheim, Bristol-Myers Squibb, and Janssen.
[email protected]
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM THE AF SYMPOSIUM 2018
VIDEO: Lean body mass linked to atrial fib etiology
ORLANDO – Results from a large Danish epidemiologic study published in 2017 upended the traditional view that obesity directly contributes to new onset atrial fibrillation by instead fingering lean body mass as the key body-habitus culprit.
“It’s a very different way of thinking about obesity” and it’s relationship to the etiology of atrial fibrillation, Stanley Nattel, MD, said in a video interview at the annual International AF Symposium. “I wouldn’t qualify it yet as a complete shift,” because the results came from a single study, “but the results are quite persuasive and very interesting,” said Dr. Nattel, professor of medicine and director of the electrophysiology research program at the Montreal Heart Institute.
The study he cited tracked the incidence of atrial fibrillation during median of 17 years in more than 55,000 Danish people who were aged 50-64 years old at baseline, and showed that lean body mass was the predominant anthropometric risk factor for new-onset atrial fibrillation (J Am Coll Cardiol. 2017 May;69[20]:2488-97). When the article appeared, it was accompanied by an editorial written by Dr. Nattel (J Am Coll Cardiol. 2017 May;69[20]2498-501).
“People had not thought a lot in the past” about lean body mass and atrial fibrillation, he noted.
If the finding is confirmed, it might make sense to target screening for atrial fibrillation to people with higher levels of lean body mass, Dr. Nattel suggested.
ORLANDO – Results from a large Danish epidemiologic study published in 2017 upended the traditional view that obesity directly contributes to new onset atrial fibrillation by instead fingering lean body mass as the key body-habitus culprit.
“It’s a very different way of thinking about obesity” and it’s relationship to the etiology of atrial fibrillation, Stanley Nattel, MD, said in a video interview at the annual International AF Symposium. “I wouldn’t qualify it yet as a complete shift,” because the results came from a single study, “but the results are quite persuasive and very interesting,” said Dr. Nattel, professor of medicine and director of the electrophysiology research program at the Montreal Heart Institute.
The study he cited tracked the incidence of atrial fibrillation during median of 17 years in more than 55,000 Danish people who were aged 50-64 years old at baseline, and showed that lean body mass was the predominant anthropometric risk factor for new-onset atrial fibrillation (J Am Coll Cardiol. 2017 May;69[20]:2488-97). When the article appeared, it was accompanied by an editorial written by Dr. Nattel (J Am Coll Cardiol. 2017 May;69[20]2498-501).
“People had not thought a lot in the past” about lean body mass and atrial fibrillation, he noted.
If the finding is confirmed, it might make sense to target screening for atrial fibrillation to people with higher levels of lean body mass, Dr. Nattel suggested.
ORLANDO – Results from a large Danish epidemiologic study published in 2017 upended the traditional view that obesity directly contributes to new onset atrial fibrillation by instead fingering lean body mass as the key body-habitus culprit.
“It’s a very different way of thinking about obesity” and it’s relationship to the etiology of atrial fibrillation, Stanley Nattel, MD, said in a video interview at the annual International AF Symposium. “I wouldn’t qualify it yet as a complete shift,” because the results came from a single study, “but the results are quite persuasive and very interesting,” said Dr. Nattel, professor of medicine and director of the electrophysiology research program at the Montreal Heart Institute.
The study he cited tracked the incidence of atrial fibrillation during median of 17 years in more than 55,000 Danish people who were aged 50-64 years old at baseline, and showed that lean body mass was the predominant anthropometric risk factor for new-onset atrial fibrillation (J Am Coll Cardiol. 2017 May;69[20]:2488-97). When the article appeared, it was accompanied by an editorial written by Dr. Nattel (J Am Coll Cardiol. 2017 May;69[20]2498-501).
“People had not thought a lot in the past” about lean body mass and atrial fibrillation, he noted.
If the finding is confirmed, it might make sense to target screening for atrial fibrillation to people with higher levels of lean body mass, Dr. Nattel suggested.
EXPERT ANALYSIS FROM THE AF SYMPOSIUM 2018
