All right, well, welcome. This is the Clinical Spotlight Session for Rapid Review, AFib, the Latest in Management Strategies. I'm Julia Indyk, your chair for tonight. I'm an EP physician from the University of Arizona in Tucson, where I'm also the program director for the Cardiology Fellowship Program. And I'm joined today by an amazing group of individuals. And I want to first do some introductions and welcomes. First, and foremost, our clinical facilitators tonight. We have Dr. Nicholas Tan, who is an EP fellow at Mayo Clinic, and Dr. Tiffany Hu, who is a cardiology fellow, soon to be EP fellow, also from the Mayo Clinic. And then we have a very prestigious faculty tonight. They include Dr. James Freeman from the Yale University School of Medicine, where he's Associate Professor of Medicine and Director of the Yale Atrial Fibrillation Program and Director of the Cardiac EP Laboratories. We have Dr. Cynthia Tracy, who hails from the George Washington University Hospital as Professor of Medicine. She is also Director of Electrophysiology and part of the AFib Center there. We have Dr. Michael Gold from the Medical University of South Carolina, where he's the Michael E. Asse Professor of Medicine and also prior President of the Heart Rhythm Society. And Dr. Dharam Kumbhani from UT Southwestern Medical Center. He's Associate Professor of Medicine and the Director of Interventional Cardiology. So a warm welcome to everyone here. So let me just go through some of these slides here. I first want to acknowledge the support that we received. Independent educational grants from Janssen Pharmaceuticals, administered by Janssen Scientific Affairs, LLC, and Sanofi. Let me go to the next slide here. Claim credit or certificate of participation. So you'll receive a link via your email to claim 1.5 hours of CME, MOC, or CME credit or your certificate of participation. Masks are required except while actively eating and drinking. And then let's bring up the ARS concepts. You take your phones. You can scan QR codes also, I'm told, from the piece of paper that's there on your tables. Open up the app on your mobile device, select the session and the ARS icon, and then respond to our poll. You can also go to the browser link. And in order to give everyone a chance just to try it out, we'll do this polling question. So how are you participating in this session? You get 60 seconds. So go ahead and do it. See? I had to learn how to do that. So how are you participating in this session? So time passes so slowly. Can you believe we have another 20 seconds to wait? Nine, eight, seven. Great. And so the reason why it is so long here is because to give the people who are participating virtually a chance as well. All right. So without further ado, so here's the name of the game. We're going to start to just wet your appetite beyond just your food with some cases to think about and also to poll with ARS. But you want to then keep it in the back of your mind. We're then going to listen to the lectures, and then we're going to come back and represent the cases with answers and have our panel discussion as part of that. So with that, and to present these cases, I want to bring our clinical facilitators, Dr. Tiffany Hu and Dr. Nicholas Tan, and we'll start with Dr. Hu. Thank you, Dr. Indyk and ACC, for the invitation. For case one, we have a 65-year-old woman who presents in clinic for follow-up. Past medical history is notable for persistent atrial fibrillation on rivaroxaban, hypertension, diabetes, mellitus, and obstructive sleep apnea. She had been complaining of increasing dyspnea when she goes on her evening walks. She undergoes exercise nuclear stress testing, shown to the right, which revealed reversible apical ischemia. You titrated her medical therapy. However, she had persistent symptoms, and therefore, she underwent coronary angiography. She receives a drug-eluting scent to her mid-LAD and is prescribed clopidogrel upon discharge. On exam, she appears comfortable and euvolemic. Her radial arterial site is well-healed. Her labs demonstrate a hemoglobin of 12 and a creatinine of 0.8 with an EGFR of 60. Here comes our first question. Which of the following is the best anticoagulation plan in the setting of her clopidogrel use? A, rivaroxaban 20 milligrams daily with dinner. B, rivaroxaban 15 milligrams daily with dinner. Switch to a vitamin K antagonist, goal INR 2 to 3. Switch to vitamin K antagonist, goal INR 2 to 2.5. About halfway through for time. Excellent. We have nearly 100 votes. Let's try to get above 100 here. So close. Excellent. 20 seconds left. A couple more seconds for last-minute voters. Okay, our poll is closing. And the most common answer was A. This same patient that we just talked about develops heart failure with preserved ejection fraction over the next several years. She is hospitalized for heart failure exacerbation three times in the past year. She leaves the hospital with end-stage renal disease, now requiring dialysis. Her sister suffered a stroke while on vitamin K antagonist with a subtherapeutic INR, and therefore she prefers to avoid vitamin K antagonists. Medications include metoprolol, amlodipine, rosuvastatin, rivaroxaban 20 milligrams daily, and insulin. Weight is 55 kilograms. So here comes our second question. Which of the following is an appropriate anticoagulation strategy? A, rivaroxaban 15 milligrams daily with dinner, rivaroxaban 10 milligrams daily with dinner, C, dipicotran 75 milligrams twice daily, or D, apixaban 2.5 milligrams twice daily? Please send us your answers. We have about 30 seconds left. Ten more seconds for last-minute votes. 75% voted for apixaban 2.5 twice daily. We'll be moving on to case number two. This is a 70-year-old gentleman who presents to clinic for follow-up. He has a history of lung cancer, COPD, permanent atrial fibrillation on apixaban 5 milligrams BID, and CKD stage 3 with a creatinine of 1.3, EGFR of 56. He previously reported several months of dyspnea and chest pain. He undergoes coronary angiography shown to the right. He is found to have severe mid-LAD disease for which he receives a drug-eluting scent. He is discharged on aspirin 81 milligrams daily and clopidogrel 75 milligrams daily, in addition to his apixaban 5 milligrams twice daily. He is seen in clinic one month later. At this time, what is the next best step? A, continue current therapy for five more months, then discontinue clopidogrel, continue apixaban indefinitely. B, discontinue aspirin now, continue clopidogrel for five more months, continue apixaban indefinitely. C, discontinue aspirin now, continue clopidogrel for 11 more months, continue apixaban indefinitely. Or D, discontinue apixaban now, continue aspirin and clopidogrel indefinitely. Please send us your votes. Thank you. Ten more seconds here. Okay, about half voted for C. Case three, we have a 75-year-old woman who presents to the emergency department with vague chest discomfort. Her past medical history is notable for hypertension, sick sinus syndrome, status post dual chamber pacemaker, obesity, CKD stage three. Her ECG shows nonspecific SCT wave abnormalities. High sensitivity troponins are 20 and 50. She is hospitalized and undergoes coronary angiography the following day. This reveals a 90% lesion to the mid-right coronary artery for which she receives a drug-eluting stent. Three months following hospital discharge, she continues to do well at cardiac rehab. She lives alone and ambulates independently. Medications include metoprolol, dicinopril, atorvastatin furosemide, aspirin, and clopidogrel. On her device interrogation, she is noted to have several new episodes of atrial fibrillation. Five of the seven episodes lasted greater than 24 hours. The diagnosis of atrial fibrillation is new. You are seeing her for follow-up three months after her end STEMI. And we'll open the poll here. And please vote as I read out the answers here. Option A, continue aspirin and clopidogrel for nine more months. B, start apixaban, continue aspirin and clopidogrel for nine more months. C, start apixaban, stop both aspirin and clopidogrel. Or D, start apixaban, stop aspirin, and continue clopidogrel for nine more months. We're about halfway through here. Ten seconds left. And our poll's going to close here. Eighty-three percent voted for D. Pass it off to Dr. Tan. Thank you, Dr. Hu. So case four, a 71-year-old woman presents for further management of assistant A-fib diagnosed by her primary care doctor one month earlier. So she experiences pounding in her chest whenever she walks her dog. She was started on metoprolol 25BID with no difference in symptoms and then started on anticoagulation as well with apixaban. Background, she was diagnosed with atrial fibrillation at the end of her first year of high school. Anticoagulation as well with apixaban. Background history includes diabetes, hypertension. She underwent an echocardiogram that demonstrated an ejection fraction of 58 percent and her heart rate in the office was 93 beats per minute. So first question here, to prevent cardiovascular-related death, stroke, heart failure, hospitalization, or acute coronary syndrome, what is the next best step? So A, increase metoprolol. B, add diltiazem. C, get a cardioversion and initiate flaconide. Or D, continue current therapy. 15 seconds left. So about 45 seconds. So about 43 percent of people picked increasing metoprolol. So the patient elected to continue metoprolol at this stage. She started having more palpitations and more exertional dyspnea, and her husband eventually took over the dog walking duties. So question two, to improve her symptoms and quality of life, what is the next best step? A, cardiovert and initiate amiodarone. B, catheter ablation. C, add diltiazem. D, continue current therapy. Or E, implant a pacemaker and add diltiazem. So about half elected for catheter ablation. Okay, moving on to the next case. A 76-year-old man with a history of hypertension, CAD, status post-PCI to the LAD back in 1999, currently not on antiplatelet therapy, long-standing persistent atrial fibrillation, asymptomatic on the PIXA band for anticoagulation, presents the emergency department with a severe headache, memory difficulties, and aphasia. Blood pressure at the time was 185 over 105. His CT is as demonstrated on the right, showing an acute bleed. So you see him in clinic six months later. Thankfully, he recovered well from his stroke. Aspirin was resumed due to his history of coronary artery disease, and the CHAD-VET score was four and HAS-VET score was four. At this time, what is the next best step? A, start Warfarin with a target INR of 2 to 3. B, resume a PIXA band. C, pursue percutaneous left atrial appendage occlusion. D, start aspirin 325. Or E, no further intervention. Fifteen seconds. So most people wanted to go for left atrial appendage occlusion. Good. All right, so the patient did undergo Watchman FLEX implantation and had no immediate complications. So now, which one of the following is the most appropriate antithrombotic therapy post-implantation in this situation? A, no oral antiplatelet or anticoagulant. B, aspirin and clopidogrel for six months and then aspirin indefinitely. C, aspirin and Warfarin for 45 days, then aspirin and clopidogrel until six months post-implant, then aspirin indefinitely. Or D, aspirin and a PIXA band for 45 days, then aspirin and clopidogrel until six months post-implant, and then aspirin. Okay. Last ten seconds. Okay, a bit more of a spread here of this one. And that's it for the questions. Thank you.

atrial fibrillation

management strategies

clinical spotlight session

anticoagulation plans

heart failure patients

symptom management