EP Update for Nurse PractionersApril 2016

AGENDAq What is atrial fibrillation?q Pharmacology of current rate and rhythm control

q Ablation-­ who, what, where, when and whyq Device therapy old and the newq Recent advances in heart failure therapy

What is Atrial Fibrillation?q An irregular heart beat generated when the top chambers of the heart are beating very rapidly.

q Atrial fibrillation compromises several aspects of heart function.¤ Rate¤ Regularity of the heart rhythm¤ Loss of loading the ventricle with blood

q Loss of the forceful atrial contraction slows blood flow in the top chambers of the heart.

What is Atrial Fibrillation?

Are there different kinds?

q Paroxysmal (self-­terminating)-­ sustained > 30 seconds

q Persistent (>7d)-­ requires shock to terminateq Permanent-­ unable to convert except with surgery or ablation

q First detected episode vs. recurrentq Secondary AF-­ pneumonia, heart surgery etc.q Lone AF-­ no other heart disease

What causes Atrial Fibrillation?

Triggers for Atrial fibrillation

Triggers

q Pulmonary veins¤ Account for ~90% of atrial fibrillation in men¤ 80% in women

q Other thoracic veins 10% in both sexesq Nonvenous locations

¤ LA Posterior wall, CS OS, Crista Terminalisq Elimination of trigger for atrial fibrillation is curative.

Why does it keep going?

Atrial Scarring

q Injury to the heart muscle¤ Age¤ High blood pressure¤ Structural problems in the heart

n Heart attacks, valve problems, congestive heart failure¤ Sleep apnea¤Obesity¤ Alcohol¤ Repeated exercise

q All of these lead to fibrosis

Rate Control

q Structurally normal hearts¤ Calcium channel blockers and beta blockers

n Cartia XT, Metoprolol Succinate¤ Digoxin-­ RR of dying 1.5¤ Two agents 60% of patients¤ Target heart rates-­ daytime, night time, too much

q Reduced Ejection Fraction¤Metoprolol succinate¤ Calcium channel blockers contra-­indicated¤Occasional low dose digoxin as second agent

q Structurally normal hearts (Na+ Blockers)¤Flecainide (rare side effects)

q Hypertrophic cardiomyopathy¤Disopyramide (alpha agonist)¤Dronaderone (low potency)¤Amiodarone (side effects)

q Reduced ejection fraction (K+ blockers)¤Dofetilide (TdP, Female sex)¤Sotalol (inverse use dependence)¤Amiodarone

Rhythm Control

Atrial Fibrillation Ablation

q 4 catheters-­ CS, ICE, Lasso and Ablationq Goals

¤ Elimination of triggers ¤ Left atrial size reduction (electrical)¤ Elimination of flutter rhythms¤GP ablation

q Prevention of complications, limiting xray and anesthesia time

3-­D Mapping

Atrial Fibrillation Ablation

q Atrial fibrillation ablation right now¤ CT scan of the chest beforehand¤ 2 hours under general anesthesia¤ Home same day or next morning¤ Blood thinner 3 weeks before and at least 3 weeks afterwards

¤ requires >1 procedure 10% of the time.¤ Complication rate 5-­6% (mostly minor)

n Bleeding/perforation <1% (managed with a drain) n Stroke 0.2%,Esophageal injury 0.1%,Death 0.1%

Who benefits from Afib ablation?

q Younger patients (less than age 80)q Patients with symptoms (even the vague ones)q Patients with structural heart disease

¤ CAD¤ CHF-­ diastolic or systolic¤ AS?¤MR?

q Patients with SSS

Who does not benefit ablation?

q ESRD or Chronic Renal Insufficiencyq Patients with longstanding atrial fibrillation >5 yearsq Patients without symptoms from atrial fibrillation?

Zero Fluoro Ablation

q Increasing awareness of long term risk to patients and physicians of medical radiation

q Reddy et al published series of completely fluoro-­free ablation (ICE and 3D mapping)

q Over the last several years we have done the first completely fluoro-­free ablations in NM.

q Average fluoro time for atrial fibrillation ablation has dropped 90% in our lab.

Changing Landscape

q Rapid mapping of atrial tachycardiaswith multipolar catheters 2011-­2

q Contact force sensing catheters 2014¤Reduce ablation times¤Reduce re-­ablation¤Reduce perforation

Changing Landscape

q Rapid mapping of atrial tachycardiaswith multipolarcatheters 2011-­2

q Contact force sensing catheters 2014¤ Reduce ablation times¤ Reduce re-­ablation¤ Reduce perforation

Device Therapy for Arrhythmia

q Pacemakers¤ Three flavors¤ Treat bradycardias (sinus node problems, AV block)¤ Last 12 years on average¤ Detect and record fast arrhythmias

q Defibrillators (really pacemaker and Defibrillator)¤ Three flavors¤ Treat tachycardia (ventricular fibrillation, ventricular tachycardia) and bradycardia

q No devices treat atrial fibrillation!

Remote Monitoring

q ICDs and pacemakers have the ability to transmit data from a bedside device with or without patient intervention

q Atrial fibrillation, congestive heart failure, battery failure, lead malfunction, ventricular tachycardia can all be detected remotely

q Patients that engage in remote monitoring reduce their mortality by 50%.

• Based on remote transmissions from 1,484 devices at NMHI between 2008 and 2015.

• Compared NMHI to the U.S. population including >300,000 devices from Merlin.net:• Age and Gender, Device Types, Remote Monitoring and Survival

• Subset of analytics compare devices at NMHI to a random set of 10,000 devices

• Device Longevity, Biventricular and Ventricular Pacing, Zone Configuration, Tachy Detection, ATP Therapy and Safety Margins

Methods

NMHI patients have better survival outcomes than patients at other large clinics in the US.

Survival

• Mortality at a clinic is shown as a ratio that compares the actual number of reported deaths to the expected number of deaths.

• Number of expected deaths is calculated based on patient age and gender using U.S. Census data from 2010.

• Analytic includes 64 clinics that were observed to accurately report patient deaths using Social Security Death Index.

• Each clinic has between 500 to 3000 implants between 2010 to 2014.Reference: Arias, E. (2014). United States Life Tables, 2010. Centers for Disease Control and Prevention, U.S. Department of Health and HumanServices, Hyattsville, MD.Master Death File. Retrieved from Social Security Agency: http://www.ssa.gov/dataexchange/request_dmf.html

• Devices at NMHI last significantly longer than the national average. This is especially evident in pacemakers and CRT-­D devices that last a year longer on average.

• Increased longevity results in fewer device replacements which may be more cost-­effective.

• Fewer replacements also lowers complications which may be associated with higher quality outcomes for NMHI patients.

Device Type

Clinic Longevity

National Average

Increase p-­value

CRT-­D 6.8 +/-­ 1.1 years 6.1 years 13% p < 0.001

ICD-­DR 7.9 +/-­ 0.9 years 7.5 years 5% p < 0.001

ICD-­VR 9.1 +/-­ 0.8 years 8.7 years 4% p < 0.001

CRT-­P 8.1 +/-­ 1.9 years 6.8 years 19% p < 0.001

Pacer-­DR 10.1 +/-­ 1.7 years 9.0 years 12% p < 0.001

Pacer-­SR 11.7 +/-­ 1.6 years 10.6 years 10% p < 0.001

Device Longevity

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• Guidelines recommend tachycardia continue for at least 6-­12 seconds before detection is confirmed. Additionally, the slowest tachy detection rate should be between 185 and 200 bpm. This will reduce total therapies delivered which is associated with better healthcare outcomes.

• NMHI complies with these guidelines more closely than the national average.

Tachy Detection

27

Parameter Time to Detect NMHI

National Average

p-­value

VT-­1 10.8 +/-­ 2.7 s 7.0 s p < 0.001

VT-­2 9.1 +/-­ 1.9 s 6.1 s p < 0.001

VF 5.5 +/-­ 1.7s 3.9 s p < 0.001

RV pacing

q Pacing induced cardiomyopathy¤ 10% patients¤ Usually reversible¤ Traditional approaches BiV pacing and medical therapy

q HIS Bundle pacing¤ 75% of patients with AV block have normal conduction systems below the AV groove

¤ Results in physiological activation of the RBB and LBB and resolves this issue

¤ NMHI has >30 implants, first in the state

Sharma PS, et al, Heart Rhythm 2015;;12 (2): 305-­312

HIS Bundle Pacing

q What’s the data vs RV pacing?

Sharma PS, et al, Heart Rhythm 2015;;12 (2): 305-­312

Systolic Heart Failure

q Medications-­ triple therapy, triple survival¤ Target doses¤ Gradual up-­titration

q Defibrillator therapy EF≤ 30¤ NICM-­ SCD risk= 5-­7%/year¤ ICM-­ SCD risk= 7-­9%

q Salt restriction¤ Diuretic use proportional to mortality

q Early referral for MCSq Coordinated care

Diastolic Heart Failure

q Older patientsq Multiple medical problemsq Higher mortality and readmission ratesq Therapy of all of the small diseasesq Salt restriction, HTN control, Diuretics

q ?Vasodilator therapy

• Pulmonary artery pressure monitor

• Implanted in the LPA inferior branch

• No battery• Remote transmission of data

• Reduces hospitalizations by 33%

• Increases medication adjustments

• Most benefit in diastolic heart failure

• NMHI implanted the first of these devices in NM

Cardiomems

§ A surgically implanted, rotary continuous-­flow device in parallel with the native left ventricle

¤ Left ventricle to ascending aorta

§ Percutaneous driveline§ Electrically powered§ Fixed speed operating mode

§ Home discharge

LVAD Therapy

B189-­0312

Advanced Heart Failure Patients:Choosing a VAD

Grady KL, Meyer PM, Mattea A, et al. Improvement in quality of life outcomes 2 weeks after left ventricular assist device implantation. J Heart Lung Transplant.. 2001;;20:657-­69.

53%17%

14%

3%0%0%0%0%0%0%0%0%0%0%

Saved Life

No Alternative

Felt Better

Stronger for Transplant

Responses

Why Did Patients Decide to Have an LVAD?

79%

12%

6%1% 1%0%0%0%0%0%0%0%0%0%

Definitely Yes

Probably Yes

Not Sure

Probably No

Definitely No

Responses

If Patients Could Go Back in Time, Would They Still Choose an LVAD?

Survival

Source: Park SJ, AHA 2010

• 1-­ 2 week hospital stay

• 1 year survival 90% in OHT is the target

• Both QoL measures (KCCQ and MLWHF) demonstrated significant improvement over baseline values

¨DEATH FROM HEART FAILURE IS A CHOICE!