Sunday, August 30, 2009

What’s new and exciting in atrial fib?

Dr. Timothy Fleming gave a nice overview in yesterday’s sessions. Here’s what was of particular interest to me:

The CHADS2 score is useful in clinical decisions.

Warfarin should be withheld from elderly patients with increased fall risk. Fact or myth? Myth, if their CHADS2 score is 2 or greater.

What about the percutaneous left atrial appendage occlusion device as an alternative to long term warfarin therapy? Although the PROTECT AF trial showed non-inferiority to standard warfarin treatment the procedure associated complications were very problematic, and the procedure, while worth consideration in very select patients, is not ready for general use.

Dronedarone---a non toxic amio? Maybe. No iodine moiety, no thyroid or pulmonary problems. Can be used for rate control or to maintain sinus rhythm. Associated with decreased mortality (first a fib drug to do so!) when used for rate control excluding class 4 heart failure but increased mortality seen when used in severe HF to maintain NSR. (Now who knows what hidden toxicities lurk in the post marketing experience).

Do “non-a fib drugs” prevent a fib? ACEIs yes; ARBs yes; statins maybe (didn’t quite reach statistical significance in a meta-analysis). A fib was a secondary endpoint in trials of these drugs for their approved indications.

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