Key changes in the field of cardiac arrhythmias in the past 2 years - Dr Pipin Kojodjojo
- 1. Dr Pipin Kojodjojo Senior Consultant Cardiologist / Cardiac Electrophysiologist [email protected] linkedin.com/in/pipin-kojodjojo-5611a8228 Key changes in the field of cardiac arrhythmias in the past 2 years - what you may have missed during the COVID pandemic? 20th August 2022
- 2. 4 things to tell you about: 1. Need to treat AF early 2. Combining AF symptom control and stroke prevention in a single procedure 3. We don’t pace like we used to do 4. COVID reset my thermoset
- 3. AF is a progressive, chronic disease Chang E. et al. A Stochastic Individual-Based Model of the Progression of Atrial Fibrillation in Individuals and Populations. PLOS ONE 2016
- 4. More AF, higher rates of mortality /HFH / stroke Steinberg et al. Atrial fibrillation burden and heart failure: Data from 39,710 individuals with cardiac implanted electronic devices. Heart Rhythm 2021
- 5. Long Terms Outcomes of Persistent AF Ablation are sub-optimal Schreiber et al. Five-Year Follow-Up After Catheter Ablation of Persistent Atrial Fibrillation Using the Stepwise Approach and Prognostic Factors for Success Circulation AE 2015 Predictors of recurrence: Failure to terminate AF, number of procedures, female sex, structural heart disease
- 6. Diagnosis-to-Ablation Time as a modifiable success factor in treatment of AF – think door to balloon time for the atria! Chew et al. Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies. Circ EP 2020
- 7. 66% persistent AF OAC stopped at physician’s discretion in rhythm control arm Most strokes occurred when warfarin was stopped / subtherapeutic 62.6% in rhythm control arm were in SR at 5 years Wyse DG et al A comparison of rate and rhythm control in patients with atrial fibrillation. NEJM 2002 Rate versus Rhythm Control: AFFIRM
- 8. Early Rhythm-Control Therapy in Patients with AF: EAST-AFNET4 • 2789 patients with early AF (diagnosis within 1 year) to receive either early rhythm control or usual care – 135 sites in 11 European countries – median follow-up of 5.1 years • Early rhythm control – AAD or ablation after randomization • Usual care – management of AF related symptoms (rate control) • Primary endpoint – composite of death from cardiovascular causes / stroke; hospitalisation with HF / ACS • Primary safety endpoint – death, stroke, adverse events from rhythm control Kirchhof P et al Early Rhythm-Control Therapy in Patients with AF. NEJM 2020
- 9. Early Rhythm-Control Therapy in Patients with AF: EAST-AFNET4 • 36 days since AF diagnosis, 30% asymptomatic, > 90% OAC, 88% hypertensive, mean age 70, mean CHADVASC of 3.4 • 82.1% in SR at the end of 2 years in early RC arm, 60.5% in usual care arm Kirchhof P et al Early Rhythm-Control Therapy in Patients with AF. NEJM 2020
- 10. Early Rhythm-Control Therapy in Patients with AF: EAST-AFNET4 Kirchhof P et al Early Rhythm-Control Therapy in Patients with AF. NEJM 2020 HR = 0.79 • 21% reduction in CV death, HF hospitalisation, ACS and stroke • No difference in overall primary safety outcome (16.6% vs 16.0%) • 4.9% non-fatal adverse events due to AAD in rhythm control arm (1.4% in usual care) • 0.8% non-fatal complication rate in those having AF ablation for rhythm control
- 11. ESC 2020 AF Guidelines advocates rhythm therapy in early AF and earlier role for ablation Eur Heart J, Volume 42, Issue 5, 1 February 2021, Pages 373–498
- 12. * Major bleeding was defined according to ISTH criteria Adapted from Granger et al. N Engl J Med 2011;365:981-92. ARISTOTLE: Apixaban significantly reduced the risk of major bleeding* versus warfarin Patients with event (%) Months 0 6 12 18 24 30 0 2 4 6 8 Apixaban Warfarin 31% RRR HR 0.69 (95% CI: 0.60-0.80); p<0.001 No. at Risk Apixaban 9088 8103 7564 5365 3048 1515 Warfarin 9052 7910 7335 5196 2956 1491
- 13. ARISTOTLE: Apixaban significantly reduced the rate of bleeding irrespective of the bleeding definition used but it is still not 0% Outcome Apixaban (N=9,088) Event Rate (%/yr) Warfarin (N=9,052) Event Rate (%/yr) HR (95% CI) P value Primary safety outcome: ISTH major bleeding 2.13 3.09 0.69 (0.60, 0.80) <0.001 Intracranial 0.33 0.80 0.42 (0.30, 0.58) <0.001 Other location 1.79 2.27 0.79 (0.68, 0.93) 0.004 Gastrointestinal 0.76 0.86 0.89 (0.70, 1.15) 0.37 Major or clinically relevant non-major bleeding 4.07 6.01 0.68 (0.61, 0.75) <0.001 GUSTO severe bleeding 0.52 1.13 0.46 (0.35, 0.60) <0.001 TIMI major bleeding 0.96 1.69 0.57 (0.46, 0.70) <0.001 Any bleeding 18.1 25.8 0.71 (0.68, 0.75) <0.001 Adapted from Granger et al. N Engl J Med 2011;365:981-92.
- 14. Compliance with DOAC poorer than you think • Meta-analysis of > 594,000 AF patients • 67% of patients on DOAC demonstrated good compliance (>80% of tablets taken) • 69% of patients on DOAC persisted with their tablets (higher than warfarin) • Compliance / persistence with DOAC decreased over time • DOAC non-compliance associated with 39% increased risk of stroke • DOAC non-persistence associated with 455% increased risk of stroke Ozaki et al. Circ Cardiovasc Qual Outcomes. 2020
- 15. >90% of stroke-causing blood clots that come from the left atrium of the heart are formed in the LAA.1 The left atrial appendage (LAA) is a thin, sack-like appendix connected to the heart.1 The European Society of Cardiology (ESC) guidelines have been updated to include LAA closure.2 • Minimally invasive techniques are available • An alternative for AF patients at high risk for stroke but contraindicated for OAC • Potentially replace long-term OAC DUAL-ROW PRECISION ANCHORS FULL RECAPTURE and redeployment WATCHMAN FLX ball – FULLY ROUNDED closed end
- 16. Combining rhythm control with early AF ablation and stroke prevention with LAAO in a single procedure
- 17. Electrical highway and network of the heart (His–Purkinje system) Within the ventricles, a complex mesh of fibres allows for rapid, simultaneous electrical activation. Thus within 0.1 second, the entire ventricle can be activated 90 ms / 0.09 s
- 18. 18 Usual heart rate ranges from 50 to 80 beats per minute at rest Due to heart rate too slow or missing heart beats, patients experience symptoms such as: • Tiredness • Breathlessness on exertion • Giddiness and even loss of consciousness Bradycardia
- 19. Pacemakers • Battery (30g) and 2 wires • More than 1 million implanted worldwide yearly • More than 9 million people carry a pacemaker today • Done under local anaesthesia • Battery lasts > 10 years • No restrictions on travel, driving, work • Unchanged over the past 20 years
- 20. 20 Let’s talk about railways Misconception 1- AV or Bundle Branch Block SA node AV node RBBB LBBB X
- 21. Traditional pacing – abandon the old railroad and network, build a new one but…… Newcastle
- 22. Conduction system pacing – jump over the gap and make use of the same extensive network
- 24. Better outcomes of conduction system pacing versus traditional pacing Vijayaraman, P. et al. J Am Coll Cardiol. 2018;72(8):927–47.
- 25. 10% of patients with a traditional pacemaker will develop heart failure due to the pacemaker Vijayaraman et al. Outcomes of His-bundle pacing upgrade after long-term right ventricular pacing and/or pacing-induced cardiomyopathy: Insights into disease progression Heart Rhythm 2019 60 patients with pacing induced heart failure reversed with conduction system pacing
- 26. Conduction system pacing is associated with fewer cases of new onset AF Ravi et al. Development of New-Onset or Progressive Atrial Fibrillation in Patients With Permanent His Bundle Pacing Versus Right Ventricular Pacing: Results From the RUSH HBP Registry. JAHA 2020
- 28. Leadless (without wires) pacemaker – first implanted in Singapore by AHVC team
- 29. Long COVID – Autonomic dysfunction Study of 24 Long COVID patients with cardiovascular symptoms – referred for tilt testing (Ref: Jamal et al. JACC 2022) • Determine the nature of their autonomic dysfunction • Counsel patients about their symptoms / lifestyle modifications • Short term pharmacological therapy • Autonomic rehabilitation
- 31. Take home messages • Early rhythm control provides the best long term outcomes for patients • Effective ablation combined with LAA occlusion can be a one-stop, drug free solution for suitable AF patients • Conduction system pacing is physiologically superior and should be performed in all patients receiving leaded pacemakers • Availability of leadless pacemakers • Long COVID symptoms are largely due to autonomic dysfunction