2020 Atrial Fibrillation

Jeffrey Goldberger, M.D.

Professor of Medicine
 The Statistics - Summary
• Lifetime risk for developing AF is approx 25% once
you reach age 40
• AF affects over 5 million Americans
• AF is projected to affect > 12 million by 2050
• 15% of strokes in the US are attributable to AF
• Catheter ablation success rate for persistent atrial
fibrillation - 50%
 2014 AF Guidelines
• Initial Diagnostic Evaluation
– History & PE
– ECG
– Echo
– TFTs
– Renal/hepatic
Advances in AF in Clinical Practice
• Diagnostic
– CHADS2/CHA2DS2-VASc
– Monitoring – Auto AF detection, ILR
• Therapeutic
– Anticoagulants – dabigatran, rivaroxaban,
apixaban, edoxaban
– Antiarrhythmics – dofetilide, dronedarone
– Ablation – Pressure-sensing catheters, balloon
ablation technologies, catheter/surgical tools
– LA appendage closure – Watchman, Lariat
– Rate control – AV node ablation and PM ± BiV
• N=150
• BMI > 27
• Symptomatic AF
• Intervention group - physician-led weight loss
program
• Control group - self-directed general lifestyle
measures
Abed et al JAMA 2013
Total AF-free survival (multiple ablation
procedures with and without drugs)

Pathak et al JACC 2015

Prevalence of Obesity and DM
 Background : Epicardial Fat and AF
• In the Framingham Heart
cohort involving 3217,
pericardial fat shown to
be an independent MV
predictor of the
development of AF (HR
1.28; 95% CI 1.03-1.58.

• It has been proposed that

pro-inflammatory and
pro-fibrotic cytokines
may diffuse from EAT into
the adjacent myocardium
and promote arrhythmias
 Novel Medical Adjunctive Therapy to
Catheter Ablation for Atrial Fibrillation
Liraglutide Effect In Atrial Fibrillation
(LEAF) Study
Weight loss at 3 months in LEAF– prelim
results
 Current AF stroke risk stratification
Risk Score C Statistic (95% CI) P Value

AFI 1994 0.573 (0.470-0.676) 0.209

SPAF 1999 0.549 (0.435-0.662) 0.405
CHADS2-classic 0.561 (0.450-0.672) 0.296
CHADS2-revised 0.586 (0.477-0.695) 0.140
Framingham 0.638 (0.532-0.744) 0.018
NICE 2006 0.598 (0.498-0.698) 0.094
ACC/AHA/ESC 2006 0.571 (0.461-0.680) 0.228
ACCP 2008 0.574 (0.465-0.683) 0.204
CHA2DS2-VASc 0.606 (0.513-0.699) 0.070

• Current risk scores have only mediocre predictive

value: C statistics range 0.55 to 0.64

Lip GY et al. Chest. 2010;137:263-272

Which factors are directly related to
atrial thrombus formation?

• CHF
• HTN
• Age
• DM
• Stroke
• Vascular disease
• Sex category
 Scenarios
• 70 year old obese male with 25 year
history of hypertension requiring
multiple drugs. Never exercises.

• 70 year old fit male whose doctor first

diagnosed mild hypertension last year.
He continues to run 6 miles/day.
Disease stage
Absent Early disease – Pre-clinical – Manifest
not detectable detectable
substrate

Fibrosis

Normal Progression Pre-clinical

atrium AF
AF substrate Substrate
Atrial Triggers
Potential Mediators:
mechanical Modulating
dysfunction factors
Aging
Oxidative stress
Inflammation
Pressure overload Increased
Volume overload
EAT
thrombogenicity

Stroke

Goldberger et al Circulation 2015

 UM Areas of AF Research
• Treatment
– New mapping technology – Morphology
recurrence plot
– Liraglutide (LEAF)
• Stroke prevention
– 4D flow MRI
Cardiovascular Disease in Hispanics
Mauricio G. Cohen, MD, FACC
Professor of Medicine
Cardiovascular Division, Department of Medicine
Director, Cardiac Catheterization Laboratories

@DrMauricioCohen
Hispanic Presence in the United States

 Many states have Spanish names (Colorado, Texas, California,

Arizona)
 In 1609, 11 years before the Pilgrims landed at Plymouth Rock,
“Mestizos” (mixture of Indian and Spanish) from northern
Mexico settled in what is now Santa Fe, New Mexico
 Spanish speaking settlers also arrived to Texas in the 1700s,
and to California and Colorado in the 1800s.
 The oldest city under the American flag remains San Juan,
Puerto Rico (1521).
 Who is considered Hispanic or Latino in the US?

 The term Hispanic was coined by the Office of Management and

Budget in 1977 to standardize data collection and to provide a
common denominator to a large heterogeneous population
 Hispanic: any person who classifies him or herself in one of these
origin categories
 Mexican
 Puerto Rican
 Cuban
 Other Spanish/Hispanic origin
 Hispanics can be of any race

OMB 1977, Revised 1997

https://wonder.cdc.gov/wonder/help/populations/bridged-race/directive15.html
 US Census Bureau Relies on Self-Reporting

The 2020 census form will ask the question this way:

Who is Hispanic? Anyone who says they are. And nobody who says they aren’t.

https://www.pewresearch.org/fact-tank/2019/11/11/who-is-hispanic/
Hispanic or Latino Population in the US

Mexican
9.2 Puerto Rican
Cuban
3.7 Salvadoran
64.9 3.6 Dominican
3 Guatemalan
2.2 Colombian
1.9 Honduran
1.4 Ecuadorian
1.2 1.3 Peruvian

US Hispanic Groups by Origin: 2010 US Hispanics by Age and Sex: 2010

Hispanics Have Lower Socioeconomic Status,
but Most are Employed
The majority of Hispanics in the United States are
employed (66.4%), similar to the 64.0% rate for NHWs.

Household wealth across racial and Percent composition of racial and ethnic groups in
ethnic groups high-risk/low-social-position occupations

Rodriguez CJ et al. Circulation 2014;130:593–625

 Hispanics in the U.S. workforce

In five years, Hispanics will account for about 20% of the U.S. workforce and
over 30% by 2050 (Source: Unidos US)

Forbes, Feb 11, 2019

 The Latino GDP

https://salud-america.org/latinos-economy-us-growth-future/
 Hispanics/Latinos & Cardiovascular Diseases

Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association
Benjamin EJ et al. Circulation. 2019;139:e56–e528
Hispanics/Latinos & CVD - 2016 Statistical Fact Sheet
 Diabetes in Hispanics
 Different Hispanic groups have different rates of diabetes
 26 % of Puerto Ricans
 24 % of Mexican-Americans
 15 % of Cuban Americans
 Mexican Americans have greater overall adiposity and an
unfavorable distribution of body-fat
 Diabetic Mexican Americans have
 More severe hyperglycemia
  incidence of end-stage renal disease and proteinuria
  prevalence of retinopathy

San Antonio Heart Study

Rise in the Incidence of Diabetes (1987-1996)
7- to 8-year Follow-Up in the San Antonio Heart Study

20 p=0.001 1987

15.7 1996
15
p=0.07
9.4
10
5.7
5
2.6

0
Mexican-Americans Non Hispanic Whites

Burke et al. Arch Intern Med. 1999;159:1450-6

 Study of Latinos (NHLBI)
• Hispanic or Latino are used interchangeably to refer to
populations who self-identify in this manner.
• Hispanics became the largest minority in the US in 2003,
and is expected to triple by 2050.
• Despite increasing obesity, diabetes, and lower
socioeconomic status, CV mortality is lower in Hispanics,
a pattern referred to as the “Hispanic Paradox”
• The longer Hispanic/Latino immigrants live in the US, the
worse some cardiovascular risk factors become.
• NHLBI initiated in 2006 the Hispanic Community Health
Study/Study of Latinos (HCHS/SOL) to recruit 16,000
Hispanics (18-74 yo) from 4 US communities with stable
population (Miami, Bronx, Chicago, San Diego).

Sorlie PD et al. Ann Epidemiol 2010;20:629–641

 • Complete enrollment: 15,079 participants
• Obesity and smoking highest among Puerto
Rican
• Hypercholesterolemia highest among
Central American men
• 80% of men and 71% of women had at least
1 CV risk factor
• Prevalence of ≥3 risk factors was highest in:
• Puerto Rican (25%)
• With less education (16.1%)
• US born (18.5%) or lived in the US ≥10 years (15.7%)
• English as first language (17.9%)

Daviglus ML et al. JAMA. 2012;308(17):1775-1784

 Acculturation and CV Risk Factors

Palacio Velarde G and Garcia E. ACC Expert Analysis

https://www.acc.org/latest-in-cardiology/articles/2019/04/29/13/36/the-role-of-acculturation-in-cvd-in-hispanics
Hispanic Paradox
• Despite the poor SES profile and CV risk profile, some studies
suggest that CVD mortality and overall mortality are lower in
Hispanics than in NHWs.
• Salmon bias hypothesis, Hispanics return to their home country to die, and
consequently, US Hispanic death numbers are underestimated.
• Healthy migrant hypothesis, whereby Hispanics who migrate to the United States
are generally healthy
• Psychosocial factors, including social support, optimism, and strong familial and
social ties among Hispanics
• With increasing acculturation and assimilation, this potential
epidemiological paradox may attenuate over time
• The Hispanic paradox should not delay the development of
interventions to improve CVD health in the Hispanic population

Rodriguez CJ et al. Circulation 2014;130:593–625

 Hispanics, Health Insurance and Health Care Access

https://www.pewresearch.org/hispanic/2009/09/25/hispanics-health-insurance-and-health-care-access/
 Racial and Ethnic Differences in the
Treatment of Acute Myocardial Infarction
Findings From Get With The Guidelines®-CAD Program

Mauricio G. Cohen, MD; Gregg C. Fonarow, MD; Eric D. Peterson, MD, MPH;
Mauro Moscucci, MD, MBA; David Dai, MHS; Adrian F. Hernandez, MD, MHS;
Robert O. Bonow, MD; Sidney C. Smith, Jr., MD

Cohen MG et al. Circulation 2010;121:2294-2301

 Results
Outcome Measures

White Black Hispanic

100 96 95 96 95 94 94
92 92 93
89 87 88
90 87 87
85
Patients (%)

80
80 78 78

70

60

50
Aspirin <24 Aspirin Beta Block ACE/ARB Tobacco Lipid Rx
h D/C D/C D/C couns
Unadjusted Mortality
White Black Hispanic
5.7% 5.0% 5.5%
N=142,593
Cohen MG et al. Circulation 2010;121:2294-2301
 Individual Performance
Measures

Aspirin within 24 hours Lipid Lowering Therapy Beta-blocker at Discharge

100 100 100
95 95
95
90 90
Patients (%)

90
85 85
80 80 85 White
75 75
Overall OR: 1.07 (1.03-1.12) Overall OR: 1.05 (1.03-1.06)
80
Overall OR: 1.07 (1.05-1.09)
70 AA vs. C OR: 1.02 (0.70-1.48)
70 AA vs. C OR: 1.40 (0.92-2.12) AA vs. C OR: 0.82 (0.57-1.17)
65 Hisp vs. C OR: 1.69 (1.09-2.61)
65 Hisp vs. C OR: 1.16 (0.74-1.82) 75 Hisp vs. C OR: 1.47 (0.94-2.27)
Black
60 60 70
2002q1
2002q3
2003q1
2003q3
2004q1
2004q3
2005q1
2005q3
2006q1
2006q3
2007q1

2002q1
2002q3
2003q1
2003q3
2004q1
2004q3
2005q1
2005q3
2006q1
2006q3
2007q1

2002q1
2002q3
2003q1
2003q3
2004q1
2004q3
2005q1
2005q3
2006q1
2006q3
2007q1
Hispanic
ACE/ARB for LVSD Aspirin at Discharge Smoking Cessation Advice
100 100 100

90 90
95
80
80
Patients (%)

70
70 90
60
60
Overall OR: 1.08 (1.06-1.10)
85 Overall OR: 1.08 (1.06-1.10) 50 Overall OR: 1.15 (1.11-1.20)
AA vs. C OR: 1.44 (0.87-2.40) AA vs. C OR: 1.03 (0.68-1.58) AA vs. C OR: 0.64 (0.36-1.11)
50 Hisp vs. C OR: 0.72 (0.42-1.27) Hisp vs. C OR: 1.07 (0.69-1.68) 40 Hisp vs. C OR: 1.14 (0.69-1.86)

40 80 30
2002q1
2002q3
2003q1
2003q3
2004q1
2004q3
2005q1
2005q3
2006q1
2006q3
2007q1

2002q1
2002q3
2003q1
2003q3
2004q1
2004q3
2005q1
2005q3
2006q1
2006q3
2007q1

2002q1
2002q3
2003q1
2003q3
2004q1
2004q3
2005q1
2005q3
2006q1
2006q3
2007q1
Cohen MG et al. Circulation 2010;121:2294-2301
 Defect-Free Care

White Black Hispanic

100
§
90
§
Patients (%)

§
80 § § * *
* * Overall, defect-free care was:
* - 80.9% for Caucasians
70 - 79.5% for Hispanics
- 77.7% for African Americans

60
Overall OR: 1.08 (1.06-1.10)
50 African American vs. Caucasian OR: 0.98 (0.79-1.21)
Hispanic vs. Caucasian OR: 1.19 (0.93-1.53)

40
2002q1

2002q3

2003q1

2003q3

2004q1

2004q3

2005q1

2005q3

2006q1

2006q3

2007q1
* p<0.01 for difference between African-American and Caucasian patients
§ p<0.01 for difference between Hispanic and Caucasian patients
The significance level of p was changed to less than 0.01 to adjust for the multiple comparisons.
N=142,593
Cohen MG et al. Circulation 2010;121:2294-2301
 Issues in Racial and Ethnic Healthcare Disparities

 Cultural and linguistic barriers – many non-English speaking patients report

having difficulty accessing appropriate translation services
 Lack of stable relationships with primary care providers – minority patients,
even when insured at the same level as whites, are more likely to receive
care in emergency rooms and have less access to private physicians
 Financial incentives to limit services – may disproportionately and
negatively affect minorities
 “Fragmentation” of healthcare financing and delivery

Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare – Institute of Medicine
 • Impact of culture and ethnicity on
health behavior and health
outcomes.
• Need to tailor and develop culturally
relevant strategies to engage
Hispanics in cardiovascular health
promotion.
• Need for a larger workforce of
healthcare providers, researchers,
and allies to CV health and
reducing CVD among the US
Hispanic population.

Rodriguez CJ et al. Circulation 2014;130:593–625

Thank you.
 Detecting Cardiovascular Issues in Athletes

Robert J. Myerburg, MD
Cardiovascular Division
University of Miami Miller School of Medicine

National Press Foundation

“Covering the Heart Beat”
January 27, 2020
 Approaches to Cardiovascular Risk in Athletes
 Incidence and causes of cardiovascular issues among
competitive and recreational athletes

 Sudden cardiac arrest/death risk during competition and

training and conditioning exercises – definition of SCA/SCD
- “Cardiac arrest” versus “massive heart attack”

 Pre-participation screening to identify previously

unsuspected/unrecognized heart disease

 Evaluation of the athlete with suspicious symptoms

 Guidelines for competitive athletes / recommendations

for recreational athletes
 Recognition of SCA Risk and Defining Causes: Incidence

 Adolescents and young adults <25 years

General population: 1/100,000-1/200,000

Competitive athletes: 1/33,000-<1/100,000

Proportional risk higher in athletes

 Adults >35 years old

General population: 1/500-1/1,000

Competitive athletes: 1/15,000-1/50,000

Proportional risk lower in athletes

RULE OF 50’s: 50% of C-V deaths

50% are first recognized C-V events
50% of C-V disabilities among
SCA survivors
CLASSIFICATIONS OF ATHLETIC RISK

INTEGRATION OF FOUR VARIABLES

Type of Activity Intensity

Competitive athletics High
Recreational sports Moderate
Incidental conditioning Low

Age at Risk Etiology of Risk

Young (<30 years) Acquired disorders
Middle (31-45 years) Developmental anomalies
Older (>45 years) Inherited abnormalities
 Classification of Sports

Maximum Voluntary Contraction [reflects afterload]

Percent Maximum O2 Consumption [reflects cardiac output]

[FROM: Mitchell JH, et l.: JACC 2005]
PREDICTION OF SYNCOPE AND SCD IN ADOLESCENTS
AND YOUNG ADULTS, INCLUDING ATHLETES
Recognizable Risk With Long Lead Times:
 Cardiomyopathies  Electrical abnormalities:
- Hypertrophic cardiomyopathy - Long or Short Q-T syndrome
- Brugada syndrome
- Dilated cardiomyopathy
 Drug-induced arrhythmias, genetic basis
 Post-congenital heart disease surgery
- Proarrhythmic medications
 Right ventricular dysplasia
- Recreational drugs
 Valvular heart disease

Recognizable Risk With Shorter Lead Time:

 Myocarditis, clinically manifest  Inflammatory or infiltrative diseases
 Drug-induced arrhythmias, random

Unrecognizable or Difficult Risk Identification:

 Anomalous coronary artery
 Myocardial bridges
 Myocarditis, subclinical
 Drug induced arrhythmia
 Electrical abnormalities:
- CPVT / Idiopathic VF
- Early repolarization
- W-P-W syndrome
 Undefined causes
American Heart Association 14‐Element Screening Tool (Maron BJ Circulation 2014)

Personal History
1. Exertional chest pain/discomfort
2. Exertional syncope or near‐syncope
3. Excessive exertional and unexplained fatigue/fatigue associated with exercise
4. Prior detection of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing of the heart ordered by a physician

Family history
8. Premature death-‐sudden and unexpected before age of 50 years due to heart disease,
in one or more relatives
9. Disability from heart disease in a close relative < 50 years old
10. Specific knowledge of certain cardiac conditions in family members: hypertrophic or
dilated cardiomyopathy, long-‐QT syndrome or other ion channelopathies, Marfan
syndrome, or clinically important arrhythmias
 American Heart Association 14-‐Element Screening (Maron BJ Circulation 2014)
Physical examination
11. Heart Murmur-‐exam supine and standing or with Valsalva, specifically to identify
murmurs of dynamic left ventricular outflow tract obstruction
12. Femoral pulses to exclude aortic stenosis
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting, preferably taken in both arms)

❖❖ Positive/abnormal screen warrants further evaluation and 12-‐lead EKG

❖❖ AHA does NOT currently recommend routine 12-‐lead ECG

Is the electrocardiogram a reliable and

efficient tool to add to this strategy?
 Framing the ECG Screening Question

 Considerations regarding ECG screening as a

routine part of clearance for competitive athletics?

Rationale Identify SCD risk in athletes

Limitations Reliability of screening ECGs

Research needs and Improved sensitivity and specificity

opportunity

Debate Cost and feasibility of programs

 Pre-participation Screening in the United States
 Personal Medical History
High school College Professional

 Detailed Family History

High school College Professional

 Complete Cardiac Examination

High school +/- College Professional

 Electrocardiogram
College +/- Professional

 Echocardiogram Professional +/-

Competitive Athletes With Symptoms of Heart Rhythm Disturbances

Palpitations – usually extra beats PVCs or PACs

Episodes of racing heart – runs of extra beats

(non-sustained tachycardia)

Sustained tachycardias (greater then 30 seconds)

– atrial fibrillation; ventricular tachycardia

Syncope due to heart rhythm disturbances

Cardiac arrest – Definition; fatal if not treated promptly

 AHA/ACC SCIENTIFIC STATEMENT: Eligibility and Disqualification
Recommendations for Competitive Athletes with Cardiovascular
Abnormalities: Task Force 9: Arrhythmias and Conduction Defects

PVCs: Athletes with single PVCs and forms no greater than couplets at
rest and during exercise testing, without structural heart disease can
participate in all competitive sports.

Non-sustained VT: NSVT, >3 consecutive PVCs lasting up to 30

seconds without CV collapse, has a higher probability of reflecting an
underlying disorder, but short runs of NSVT may be normal.

Workup should include: a 12-lead ECG and stress/echo test, and an

ambulatory monitor. Can be cleared for competition if:
- NSVT is suppressed with exercise,
- No evidence of structural heart disease,
- No molecular/ genetic disorders,
- Transient abnormalities at the time of evaluation.
 AHA/ACC SCIENTIFIC STATEMENT: Eligibility and Disqualification
Recommendations for Competitive Athletes with Cardiovascular
Abnormalities: Task Force 9: Arrhythmias and Conduction Defects

Sustained Monomorphic VT: Athletes with structurally normal hearts

and monomorphic sustained VT ablation who undergo drug therapy or
catheter ablation, and remain free of spontaneous or induced VT by exercise
testing or EPS at least 3 months after the procedure, can resume full
competitive activities.

Sustained Polymorphic VT, Ventricular Flutter, and Ventricular

Fibrillation: Athletes who manifest these arrhythmias in the presence or
absence of structural heart disease, or defined molecular/genetic disorders,
generally receive ICDs. Athletes who have these arrhythmias in the setting of
transient inflammatory or electrolyte disorders may be exceptions and may
not receive ICDs. If they remain free of episodes of these arrhythmias for 3
months after resolution of the inflammatory process, they may be considered
for re-evaluation of clearance to participate.
 Age Distribution of Sports-Related SCDs in the Overall Population
During Recreational Athletics and Among Young Competitive Athletes

[Marijon E et al. Circulation 2011;124:672-681]

- Autopsy findings based on age.

- Post-mortem genetics.
 RECREATIONAL ATHLETIC ACTIVITIES

High Intensity Moderate Intensity Low Intensity

[>6 METS] [4-6 METS] [<4 METS]

Basketball Baseball/softball Bowling

Body-building Biking Golf
Ice hockey Modest hiking Horseback riding
Racquetball Motorcycling SCUBA diving
Rock climbing Jogging Skating
Running (sprinting) Sailing Snorkeling
Skiing (downhill) Surfing Weights (non-free)
Skiing (cross-country) Swimming (laps) Brisk walking
Soccer, football Tennis (doubles)
Tennis (singles) Treadmill/stationary bike
Touch (flag) football Weightlifting (free weights)
Windsurfing Hiking
[MODIFIED FROM: Maron B, et al: Circulation, 2004]
 PRE-PARTICIPATION EVALUATION
OF RECREATIONAL ATHLETES

 No specific guidelines exist for competitive athletes,

despite much higher incidence of sudden cardiac death
risk than in young competitive athletes

 Individuals with known cardiovascular problems or

uncertain symptoms should be evaluated by their physician
and prescribed appropriate level of activity
Responses to Sudden Loss of Consciousness During Athletic Activities

Be prepared!
 Basic life support available during training and competition
 Automated external defibrillators (AED) at training sites
and stadiums and arenas

Respond rapidly!
 Evaluate unconscious victim immediately – pulse, breathing?
 Start CPR in 2 minutes or less
 Call 911 if not already on site
 Deploy automated external defibrillator ASAP
Thank you.