Anti-Arrhythmics 101 (Craig Pratt, MD)

Houston Methodist DeBakey Heart & Vascular Center

You guys all good today for endurance i’m amazed it’s almost sunday at noon and you’re here i want to talk a little bit about antiarrhythmic drugs i’m going to fudge a little bit and talk a little bit about an equation and try to be done in time this is the current guidelines what’s really happened over time is that there’s been a definition of different degrees

Of structural heart disease and equating that with individual drugs the other thing that’s happened is something called catheter ablation and i’ll leave it to the ep guys to talk about that most importantly here for coronary artery disease and heart failure you have limited samples for no are structural heart disease fleck annoyed and propafenone work pretty well

In some countries even pill in the pocket for rare or unusual cases of paf well we want to prevent recurrence of atrial fibrillation but we all always do so because we think we’re going to be reduce mortality and morbidity right that’s it’s difficult to show the association in many cases we can show that in a disproportional fashion propafenone decreases the

Recurrence of atrial fibrillation and in patients who have no structural heart disease is probably a very good drug sotalol used sometimes with patients with ca d in afib also does the same thing notice the difference between placebo and deal soda law is 20% so you only get a 20% gain over a period of 1/2 to 1 year by using the drug and you’re stuck with a drug

For a long time a pretty woeful record actually so what about amiodarone not a proof rachael fibrillation united states so what it’s the drug used by most house officers and by most hospitals as there is there a literature to support that there’s a ctf trial which is probably the best of the trials to show that a recurrence of atrial fibrillation on a mio is better

Than doses of sotalol or purple fauna and that’s a de niro you should be aware of that paper pretty important paper well it’s amiodarone safe this is a compilation of five clinical trials over 3,000 patients relative risk of being on a mio is one it has positive effects for atrial fibrillation but it certainly does not prevent sudden death and it’s been sort of

The poster boy to compare two i cds where it always loses so what about it what about the athena trial that was a trial that i was very excited about miguel was very skeptical he wins it showed an effect on major events in patients with atrial fibrillation so drona tyrone had been studied in andromeda and proven in patients with lv systolic dysfunction and severe

Heart failure to be lethal this is the athena result it looks like death and hospitalizations are reduced looks very promising relative risk 0.76 and if you go through the other issues like worsening heart failure myocardial infarction it reduced everything the problem is there’s two trials pallas and andromeda tell us to be very careful in everybody but people

With no structural heart disease what this did give us is a great volume of amiodarone therapy on elderly patients and it does prevent recurrence of atrial fibrillation but not as well as a amiodarone so amiodarone compared to any other enter of mek wins and direct comparisons the ctf dionysius which is the duran duran trial amiodarone does not win head-to-head

For si ease it’s the world champion for si es and even with amiodarone afib is r is frequent in patients with any kind of structural heart disease so the strength of the red arrow nor reduce events in a carefully defined population it’s been using the elderly a lot and dromeda makes us a little bit worried about who we treat it with and dosing is very simple

There’s one dose the weaknesses modest efficacy certainly not as good as amiodarone small experience and believe it or not young patients where usually these drugs have been studied and a small patient experience in pif it can’t be used in the area of unmet medical need which is curing atrial fibrillation and people with structural heart disease and there’s no

Dosing option if you break through and with that one drug there’s two trials that are notable one was 12 years ago that’s this one the affirmed trial and won by first author again in canada deni rawa eight years ago and both of them were large clinical trials trying to show the rate control and anticoagulation is better than anticoagulation is better than having

An terrific drugs on board and both of them have come to the same conclusion and that is that the addition of anti rhythmic drug leading to less atrial fibrillation does not affect mortality a disappointing thing i didn’t put robbaz but that’s eight years old in new england journal so we can continue to have the the concept that recurrence of atrial fibrillation

Leads to reduce more relate to a reduction in mortality and morbid events but with anti rhythmic therapy we haven’t proven that in fact it’s been pretty disappointing the other big area that has not been disappointing is the development of a lot of anticoagulants as alternatives to warfarin i think it’s worth doing this so i want to take just a couple minutes and

Point out the strengths and weaknesses of either each of these drugs for warfarin it’s independent of renal function and can be monitored so the very thing that we’re trying to prevent people coming into the doctor all the time or his nurse or as mp is also considered an advantage because you at least know where you are there are established reversal strategies

Although they still take 24 hours or so it’s inexpensive there’s a 30-year familiarity concomitant aspirin and clopidogrel data are available but even in expert hands even in our coagulation clinic i doubt we do better than 65 70 % inr 2 to 3 and that’s true of the major clinical trials that were done in this area there are sip 450 interactions there’s a lot of

Problems okay what about dabigatran i don’t know you all i read you new england journal last week there’s the first antidote it’s a small part of antibody i can’t pronounce the name it begins with od and ends with mab and it’s a compilation of about 90 patients some of whom have had bleeding on during it on dabigatran and some people who have had that urgent need

For surgery and in both these cases it was able to reverse a lot of the clotting factors and measurements within minutes now this may lead to thrombosis it’s the first report it’s not approved but look for it coming sooner than later and it’s one of the major criticism of all the no acts was that they don’t have a an established strategy for reversal river rock seban

Major major advantage to me once a day and that is a big deal for compliance so that’s an important issue disadvantages not superior to warfarin for stroke prevention sip for 50 interactions renal adjustment is important and needs to be checked on a regular basis not one time only apixaban is my choice of the litter here the reason for it is superior efficacy and

Superior safety compared to warfarin realizing it’s hard to to compare between groups because there are different placebo groups but the bottom line is it came out looking better in both efficacy and safety it’s fast onset you’re anticoagulated within three hours and two independent trials have established not only the none for hora t but the superiority there is a

Know establish monitoring strategy the sip for 50 interactions are useful to know about in renal adjustment is really imperative the most recent of these group is inductive and it also is once a day that’s probably its claim to fame i have here carefully worded superior efficacy and safety compared to warfarin and modified intention-to-treat what that means is that

Their primary analysis was an intention-to-treat and it didn’t have a p 0.05 so they report the other one okay i’m going to play up a device like you’ll may be shocked but i think the watchman trial is pretty pretty spectacular we have two trials now protect af about for about 700 patients prevail 400 non-inferior for stroke and prevail and superior in protect af

And the data looks pretty good to me as a non electrophysiologist the the more recent thing is a lariat as i understand it maybe has a little bit more of a learning curve and so adverse events are substantial it’s in a much earlier stage of development miguel could probably tell you whether he thinks is going anywhere or not but lack of clinical outcomes for stroke

Or it’s systemic embolism at this time okay so remember we’re always trying to prevent recurrent afib because we want to reduce more ability morbidity and mortality i’m done you

Transcribed from video
Anti-Arrhythmics 101 (Craig Pratt, MD) By Houston Methodist DeBakey CV Education