Beta-blockers or Digoxin for atrial Fibrillation

And heart
Lurent Fauchier. Guillaume failure
Laborie, Nicolas Clementy, and
Dominique babuty

Muhammad Riza Qadafi R

18174091
Penguji
Dr. Nursanty, Sp.s
Place Your Picture Here
BACKGROUND

Atrial Fibrillation (AF) & Heart Failure (HF)

Are common conditions that frequently
coexist and share multiple risk factor.
The Purpose of this
study

“ To review the effect of

betablockers, digoxin and their
combination in patients with AF
and HF.
Rate Control Atrial Fibrillation with Heart Failure
Major part of therapy for all patients with AF

1. Betablockers Reduce VR and improve

2. Non-dihydropyridine CCB (diltiazem) symptom
3. Digitalis
Prevent deterioration, improve exercise
tolerance and quality of life, prevent
hospitalisation

1. A study by jabber et all recommend

that treathment for rate control of AF
should aim for < 100 bpm
 Beta-Blocker
Currently a cornerstone in the treathment of patients with HF and
reduced EF (ejection

In AF, beta-blocker are preferred as a RATE CONTROL agent in Metoprolol >

patients after MI and patient with CHF they may avoided in patients Carvedilol
with pulmonary disease and at risk of bronchocontriction

Treathment effect, judged by reduction in all-cause mortality, seemed

to be less in 3066 patient with HF than in the 13.496 patients not in AF

In A recent cohort nationwide cohort in Taiwan and The Swedish Heart

Failure Registry, beta-blocker was associated with reduced mortality
both in SR and in AF
 Digoxin
Digoxin and other related cardiac glycosides have benn used for more
than 200 years for treathment of HR, and almost for rate regulation in AF

Digoxin reduced HF hospitalisasion and there was no significant overall

effect on mortality

Digoxin as 1. Increasing parasympathetic and

Neuromodulator decresing activation of sympathetic
nervous system and RAA system

Slows firing at the AN node and

prolongs conduction at AV
node
Based on US Guidelines , digoxin as a rate control no onger a
class1 indication

As a consequence, digoxin is commonly used by elderly

people, with a high risk profile, and a less favorable prognosis

Mortality higher in
RIKS-HIA examined 1 year outcomes patients on digoxin with
the 4426 digoxin-
AF and who were not receiving digoxin
treated patient

In 1269 consecutive patient with both AF and HF we found

after through adjustment on baseline characteristics that
treathment with BB alone or with digoxin was associated with
similar decrease in the risk of death
 Digoxin was associated with a neutral effect on mortality in
randmised trials and a lower rate of admissions to hospital
across all study types

The relationship between digoxin effect and/or toxicity and

drug concentration poorly defined, An SDC of 0,5 – 0,8 ng/ml
is the optimal therapeutic range for digoxin and from AFFIRM
found that 2ng/ml or higher may be harmful

The relationship between digoxin effect and/or toxicity and

drug concentration poorly defined, An SDC of 0,5 – 0,8 ng/ml
is the optimal therapeutic range for digoxin and from AFFIRM
found that 2ng/ml or higher may be harmful
 CONCLUSION
Rate control therapy most often includes
a beta-blocker

Digoxin mainly give to elderly AF patients

with HF and impaired LV function

Digoxin’s use is associated with increased

crude rates of mortality

Digoxin should not be used as the initial

therapy for active patients

Digoxin should be reserved for Rate control in

AF who are sedentary or who left Ventricular
systolic disfuntion
 CONCLUSION
When Beta Blockers do not achieve
sufficient rate control and when they are
poorly tolerated or contraindicated
 Result
In hospital use of oral anti coagulation or platelet inhibitors

6-7%
67% patients receive OAC at hospital

27 % start OAC later

27%
67%

OAC is assumed not to be feasiblen 7 %

 Result
Asetyl salisilat is used in 99 % started 100 mg ASA
most af patients, if OAC is
considered of feared 5 %stopped more 2 days
bleeding

60 % start ASA in > 95 %

78 % stopped the day before

22 % do not start in > 50 %

17 % at the day first OAC intake
• In Hospital prescription of a specific oral anti coagulant
Stroke patience eligible for OAC Stroke patience eligible for OAC
and Naïve regarding VKA intake and previous VKA intake

> 50 % of all patience by 5 > 50 % of all patience by

01 01
% stroke unit 18 % stroke unit

26 – 50 % patience by 6 02 02 26 – 50 % patience by 30
% stroke unit % stroke unit

1 – 25 % by 70 % stroke
unit
03 03 1- 25 % patience by 46 %
stroke unit

None by 19 % stroke unit

04
04
None patience by 6 %
stroke unit
3 % → 1 specific NOAC,
30 % → 2 NOACs
46 % → out of 3
39 % → 1 out of 4
Main reasons for the prescription of specific
OAC
The Individual cardiovascular risk profile
(77%)

The availiability of an antidote ( 68%)

Consultation with GP ( 58 %)

Starting OAC in an OAC naïve patient ( 47

%)

Required dosing frequency of OAC

( 47 %)

A first epidsode of AF after the index stroke

( 42 %)

Net clinical benefit of the NOAC according

to the statement of funds regulating
reimbursement in german ( 23 %)
 Result

The different in hospital

prescription of a specific oral
anticoagulation was
statistically signifivant
( p <0,004).
 DISCUSSION
The most surviving stroke patients with
AF are discharged on OAC and, OAC
cosindered in > 90 % of AF patients

ASA useful in early stroke prevention and

regarding bleeding risk of OAC

Compared to VKA naive patience, a Vka is more

often prescribed in AF patience with VKA intake
before
Stroke unit certification level had an impact on
VKA use

Interaction between inpatient and outpatient

care is considered pivotal for the success of
long term
 The limitation of this survey

The result of this survey are based on estimations

by the responders rather than on individual patient
Contents
data

translation of the result to other health care settings

Contents are limited
CONCLUSION
The Two groups exhibit high levels of effectiveness and there was no
significant difference between reteplase and urokinase

TNT continued to exhibit an upward trend after therapy with Urokinase,

and declined with reteplase, therefore reteplase suggesting may be better
for improving myocardial damage

Complications of bleeding increased after treatmen in the reteplase group,

but not fatal bleeding occurred. One patient with urokinase developed GI
Bleeding and died
Thank You