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1、 Management of Atrial Fibrillation：Update in the EBM proofChangSheng Ma Department of Cardiology, Anzhen Hospital Capital Medical University, P.R. ChinaPrevalence of AF is increasing0.01.02.03.04.05.06.07.01990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050Proportion Aged 80 YrGo: JAMA,

2、 2001：2370Miyasaka.Circulation.2006:1192.04.06.08.010.012.014.016.0200020052021202120202025 20302035204020452050Prevalence of AF is increasingPrevalence %AgePrevalence of AF:the Rotterdam studyHeerinaga.Eur Heart J,2006,9496808 pts., F/U 6.9 yrs，prevalence 5.5%Incidence AgeIncidence of AF:the Rotter

3、dam studyHeerinaga.Eur Heart J,2006,9496808 pts., F/U 6.9 yrs，Incidence 9.9Identified AF：the tip of the icebergv14802 pts aged 65 or over14802 pts aged 65 or over，randomized to systemic randomized to systemic screening and opportunistic screeningscreening and opportunistic screeningv Systemic screen

4、ing group:9866 pts. Systemic screening group:9866 pts.v Opportunistic screening group: 4936 pts. Opportunistic screening group: 4936 pts.vF/U 12 monsF/U 12 monsv Rate of new AF case in systemic screening 1.63% Rate of new AF case in systemic screening 1.63%，v Rate of new AF case in opportunistic scr

5、eening 1.04%Rate of new AF case in opportunistic screening 1.04%Fitzmaurice.BMJ.2007,383Risk for stroke increased in lone AFJahangir. Circulation. 2007:3050Meta-analysis:antithrombotic therapy of AFHart.Ann Intern Med,2007,857trialptsRR reduced(%)Warfarin vs Placebo6290064ASA vs Placebo8487622Warfar

6、in vs ASA121296339Real world of warfarin in the elderly13.1%4.7%The first 90 days The first 90 days associated with associated with major hemorrhagemajor hemorrhage21% pts withdrawn 21% pts withdrawn warfarin for safety warfarin for safety issueissueThe higher risk of The higher risk of stroke, the

7、higher stroke, the higher incidence of major incidence of major hemorrhagehemorrhageHylek. Circulation.2007,2689 HR for ICH was 4.06 for AsiansAsians were at greater risk for warfarin-ralated ICHShen. JACC.2007:309 vProspective，randomize，controlv973 pts 75 years old with AFvRandomized into warfarin

8、arm (INR 2.0-3.0) and Aspirin arm(75mg/d)vMean F/U 2.7 yrsvPrimary outcome：fatal or disabling stroke, intracranial haemorrhage, or arterial embolismWarfarin versus aspirin for stroke prevention in the elderly with AF(The Birmingham Atrial Fibrillation (The Birmingham Atrial Fibrillation Treatment of

9、 the Aged Study,BAFTA study)Treatment of the Aged Study,BAFTA study)Mant.Lancet,2007,4930.831.155(0.4%)6(0.5%) haemorrhagic0.651.921(0.1%)2(0.2%)Other ICH0.360.323(0.2%)1(0.1%)Embolism48(3.8%)7(0.5%)32(2.5%)23(1.8%)21(1.6%)44(3.4%)0.0050.338(0.6%) disabling nonfatal0.00270.4824(1.8%)Total0.530.695(0

10、.4%) unknown0.00040.3010(0.8%) ischemic0.140.5913(1.0%) fatal0.0030.4621(1.6%)StrokepEventwarfarin(n=488)ASA(n=488)N(Risk peryear)N(Risk peryear)warfarinVS.ASARRWarfarin versus aspirin for stroke prevention in the elderly with AFMant.Lancet,2007,493Mant.Lancet,2007,493Warfarin versus aspirin for str

11、oke prevention in the elderly with AFAnticoagulation in clinical practice2.03/100person-yrs1.17/100person-yrs11,526 pts with AF,54.8% was on warfarinRelative risk for thromb -embolism reduced 51% in warfarin therapyThe intracranial hemorrhage rate increased in warfarin(0.46/100 person-yrs VS 0.23/10

12、0 person-yrsWarfarin was not associated with nonintracranial hemorrhage (1.05/100 person-yrs VS 1.06/100 person-yrsGo.JAMA 2003:26850 05 5101015152020252530305mg5mg10mg10mg20mg20mg30mg30mg40mg40mg40mg40mgRivaroxabanEnoxaparin873 ptsEndpoints included DVT,PE,all cause mortality Safety：major hemorrhag

13、eEndpointsSafetyEriksson. Circulation. 2006: 2374%Rivaroxaban New promise of anticoagulation？vProspective RIKS-HIAv60764 pts，AF 21459 pts,CHF 22345 pts,AF+CHF16960 ptsvF/U 1 yrvHigher mortality rate in AF without CHF pts taking digoxin (RR1.42)vSimilar mortality rate in CHF or AF+CHF pts with or wit

14、hout digoxin Digoxin and mortality in AF:A prospective cohort studyHallberg.Euro J Clin Pharmacol,2007,959Hallberg.Euro J Clin Pharmacol,2007,959Digoxin and mortality in AF:A prospective cohort studyAdverse effects of oral amiodaroneZimetbaum.NEJM.2007:935Bradycardia5%Prolonged QT In mostTdp1%Hepati

15、c15%Hyperthyroidism3%Hypothyroidism20%Pulmonary3%Dermatology25-75%Neurologic3-30%Corneal deposits100%Optic neuritis AAD:4%CPVA:74% AAD:4%Catheter ablation decrease the incidence of stroke755 ptsThe incidence of stroke/TIA was 1.1%0.9% occurred whithin 2 weeks of RFCA79% of pts without risk factor fo

16、r stroke and 68% of pts with 1 risk factor in sinus discontinued warfarinPatients with sinus rhythm was thromboembolic event free after the procedureOral.Circulation.2006:759Pappone . JACC.2003:185N=589Catheter ablation reduce strokePappone . JACC.2003:185Catheter ablation improve prognosisNo risk f

17、actor： ASA 81- 325mg One moderate risk factor：ASA 81- 325mg or warfarinAny high risk factor or more than one moderate risk factor: warfarinPrinciples of anticoagulationAmiodaroneAblation ！No OHD yesHTN yesconcomitanc with LVH amiodaroneablation CAD yesHF amiodaroneablation Maintain Sinus RhythmCathe

18、ter ablation is a reasonablealternative topharmacological therapy to prevent recurrentAF (IIa,C)Fuster. Circulation.2006 :e257 Indications for catheter ablationIndications for catheter ablationvThe presence of symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medicationvin rare clinical situations, it may be appropriate to perform catheter ablation of AF as first line therapyvselected symptomatic patients