9/26/2019 Jared Mil ler MD Assistant ProfessorKnight Cardiovascular Institute Electrophysiology

Top 5 Non-CHF Management PearlsOHSU

Here are the top 5…

1. HAS-BLED score (NOT-USEFUL)

2. Friends don’t let friends rate control typical atrial flutter

3. Rate control is NOT the same as rhythm control

4. The fourth pillar of atrial fibrillation management

5. Bacteria and devices: an unfortunate friendshipOHSU

#1: HAS-BLED Score

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Turakhia MP et al. Am Heart J 2013.

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Lin HJ et al. Stroke 1996.

Lang C et al. Stroke 2017.

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• CHADS2VASC• Age

• 65-74 (+1)

• >75 (+2)

• Sex

• CHF

• HTN

• Stroke (+2)

• Vascular disease

• Diabetes

Lip GY et al. Chest 2010.

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• HAS-BLED Score• Age >65

• HTN

• Stroke

• Renal disease

• Liver disease

• Labile INR

• Other meds (ie ASA)

• Alcohol use

• CHADS2VASC• Age

• 65-74 (+1)

• >75 (+2)

• Sex

• CHF

• HTN

• Stroke (+2)

• Vascular disease

• DiabetesOHSU

• HAS-BLED Score• Age >65

• HTN

• Stroke

• Renal disease

• Liver disease

• Labile INR

• Other meds (ie ASA)

• Alcohol use

• CHADS2VASC• Age

• 65-74 (+1)

• >75 (+2)

• Sex

• CHF

• HTN

• Stroke (+2)

• Vascular disease

• DiabetesOHSU

• HAS-BLED Score• Age >65

• HTN

• Stroke

• Renal disease

• Liver disease

• Labile INR

• Other meds (ie ASA)

• Alcohol use

Poli D et al. Am J Card 2017.

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Pearl #1 Summary

• Strokes are bad!• AF related strokes are worse

• Anticoagulation is good

• HAS-BLED is a HAS-BEEN, or a NEVER-WASOHSU

#2: Typical Flutter

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#2: Typical flutter

• Very hard to rate control

• Very easy to cardiovert

• Almost as easy to ablate• 97% Success rate*

• Anticoagulation considerations are near identical to atrial fibrillation

*Spector P et al. Am J Card 2009

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#3: Rate Control v Rhythm Control

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An aside…

• The decision to anticoagulate is separate from the decision to pursue a rate or rhythm control strategy

• Think of both the AF and the thromboembolic risk as markers of a diseased atriumOHSU

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Rhythm control

• Symptomatic benefit!

• AF associated with development of heart failure, dementia, etc• Though I can’t say rhythm control reverses that risk

• Not everyone needs rhythm control• But everyone deserves consideration of rhythm controlOHSU

#4: Risk Factor Modification and AF

Rate Control

Rhythm Control

Anti-Coagulation

RiskFactor

Modification

Miller JD et al. JACC 2016.

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Obesity

• Known risk factor for developing AF

• Increased left atrial size

• Increased epicardial and pericardial fat

• Chronic systemic inflammationOHSU

ARREST-AF. Pathak R et al. JACC 2014.

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LEGACY-AF. Pathak R et al. JACC 2015.

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Obstructive Sleep Apnea

• Stronger association with AF than:-BMI-HTN-DM

• During apneic episodes, fluctuations in:-Blood pressure-Sympathetic tone

Gami. Circ. 2004.

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Kanagala. Circ. 2003Fein. JACC. 2013

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Abdulla L. Europace. 2009

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Arrhythmia ManagementAnti-arrhythmic medication, cardioversion, and ablation management

Stroke PreventionInter-professional anticoagulant monitoring, Left atrial appendage occlusion devices (Watchman and Lariat)

Risk Factor ModificationInter-professional approach to manage OSA, DM, HTN, smoking cessation, diet, & exercise

OHSU Atrial Fibrillation Center

Referrals: Email: KCVIreferrals@ohsu.edu or AFCenter@ohsu.edu or

OHSU EPIC: “Referral to Cardiology” and select “Arrhythmia”

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• Clinic day:• Patient-reported outcome measure surveys done in

waiting room

• EP RN Device visit

• EP faculty

• Cardiac Psychology

• Advanced HF, HCM, ACHD

OMVAC ClinicOHSU Multidiscplinary

Ventricular Arryhthmia Clinicnazer@ohsu.edu

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#5: Device Infections

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some situations are obvious…

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Kusumoto. 2017 HRS Lead Extraction Guidelines

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Bacteremia and devices (teaching points)

• Should initiate ID and cardiology/electrophysiology consults

• Staph in blood usually means device removal

• Earlier device removal is better

• Often cultures won’t clear until the device is removedOHSU

Summary

1. HAS-BLED• DON’T-USE

2. Typical atrial flutter• Has a curative procedure• Difficult to rate control

3. Rhythm control for AF• Won’t make you liver longer• Improves symptoms

4. Risk factor modification for AF• OSA, obesity, and exercise

5. Pacemaker/ICD infections• Often can’t treat bacteremia without removing the device• Early referral is essential

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