Transcript Atrial Fibrillation by Dr. Sarma

दुःु खेषु अनद्
ु विग्न मनुः सुखेषु विगत स्प्रह
ृ ुः
िीत राग भय क्रोधुः स्स्प्ितधीर् मुननरुच्यते ॥
dukhaeshu anudwigna manah, sukhaeshu vigatha sprihah |
veeta raaga bhaya krodhah, sthitha dheer munir uchyatae ||
Never down in the dumps when confronted with sorrow
Not elated and on cloud nine when gifted with happiness
Devoid of passion, attachment, fear and anger - always
He is the one qualified as the wise by the most eminent
Dr Alan E Lindsay
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ACC/AHA/ESC guidelines on AF - Eur Heart J (2001) 22
http://emedicine.medscape.com/article/151066
http://emedicine.medscape.com/article/1530542
http://www.nhlbi.nih.gov/health/dci/Diseases/af/af_what
http://www.afibprofessional.org/
Hurst’s The Heart – Manual of Cardiology
Essential Cardiology – Clive Rosendorff
Practical Cardiology – R R Baliga, Kim A Eagle
In A Page Cardiology – Scott Kahan, Rajnish Prasad
Cardiology Explained – Euan A Ashley, Josef Niebauer
Atrial fibrillation and atrial flutter are very fast
electrical discharge patterns that make the atria
contract very rapidly, with some of the electrical
impulses reaching the ventricles and causing them
to contract faster and less efficiently than normal
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It is a supraventricular tachyarrhythmia
The most common arrhythmia seen in clinical practice
Almost 5% of the population older than 70+ years
The prevalence of AF increases dramatically with age
AF is associated with a 1.5- to 1.9-fold  risk of death
It’s characterized by disorganized atrial electrical activity
Progressive deterioration of atrial electromechanical
function with several theories of abnormal activity
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Absence of P waves – see leads LII, LIII, aVF and V1
Rapid oscillations (or fibrillary [f] waves)
Low amplitude wavelets or mostly flat base line
These vary in amplitude, frequency, and shape
AF has a typically irregular ventricular response
Irregularly irregular heart and pulse
Narrow QRS usually, reentrant pathway wide QRS
The short PR interval is due to a bypass track, also known
as the Kent pathway. By bypassing the AV node - the PR
shortens. The delta wave represents early activation of
the ventricles from the bypass tract. The fusion QRS is
the result of two activation sequences, one from the
bypass tract and one from the AV node. The ST-T
changes are secondary to changes in the ventricular
activation sequence.
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Kent pathway
Accessory pathway
Shortened PR Interval
Delta wave
Double activation
Fusion QRS complex
At risk of VF and death
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Initiating event and permissive atrial substrate
Multiple mechanisms may be present
Focal pulmonary vein triggers – enlarged RA or LA
Multiple wavelets, mother waves, daughter wavelets
Fixed or moving rotors & macro-reentrant circuits
Automatic foci in atria
Catecholamine excess, hemodynamic stress, atrial
ischemia, atrial inflammation, metabolic stress
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Due to the risk of thromboembolic disease
Due to its associated risk factors
Loss of normal atrial contraction – Stasis of blood
Development of Thrombus in the atrial appendage
Dislodged clot leads to embolic complications
Non RHD, Non valvular cases – stroke rate 5-7%
In RHD – stoke rates are 5 fold more
Mortality is doubled with underlying structural HD
AF present with a wide array of symptoms
• Majority are asymptomatic
• Palpitations, dyspnea, fatigue, dizziness, angina
• Decompensate heart failure, Polyuria ( BNP)
In addition, AF can be associated with
• Hemodynamic dysfunction, CHF
• Tachycardia-induced cardiomyopathy
• Systemic Thromboembolism
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Irregularly irregular heart beat – pulse-apex disparate
May or may not have tachycardia – depends on AVN
Variable intensity of 1st heart sound
Occasional S3; But S4 is absent in all,
Absence of ‘a’ waves in Jugular Venous Pulse (JVP)
Signs of underlying heart disease, RHD, CAD, HCM, DCM
Look for Cardiac Failure and Atrial Embolization
May have WPW associated – Ventricular rate > 200
Normally narrow QRS tachycardia, may be wide QRS
<60 yrs
1%
80+ yrs
4%
60-79 yrs
8%
Rheumatic Valvular Heart Disease (RVHD)
Diabetes, Hypertension , CAD, LV Dysfunction
Male Gender, Advancing Age, Hyperthyroidism
Congenital or Structural Heart Disease, LA, RA
Cardiomyopathy, Alcohol use, Illicit Drugs
Acute pulmonary problems, Cardiac Surgery
• Hemodynamic stress:  intra-atrial pressure
– Mitral and tricuspid valve disease, LV dysfunction
– Systemic or pulmonary hypertension
• Atrial Ischemia: CAD, Ventricular Ischemia   LAP
• SSS, Inflammation, Drug use, Alcohol
• Endocrine (hyperthyroidism), Neurologic – SAH, Stroke
• Familial Atrial Fibrillation
• Cardiac Surgery, Collagen Diseases
• AF with structural heart disease (RVHD, HT Heart,
Cardiomyopathy, Congenital Heart Disease, CAD)
• Elevated BNP suggests underlying heart disease
• AF without concomitant structural heart disease
• “Lone Atrial Fibrillation” – AF in younger patients
without structural heart disease with lower risk of TE
• Hemodynamic instability – severe dyspnea, reduced
O2 saturation, fall of BP, severe chest pain, shock etc.
• 12 Lead ECG with rhythm strip
– Look for pre excitation, Determine Heart Rate
– Evaluate for LVH, LBBB, Previous MI
– QT-QRS intervals for pts on anti arrhythmic drugs
• Six-minute walk test or exercise test (rate control)
• Holter monitoring; Electrophysiology only in selected cases
• Echocardiography (TTE), TEE (to study the atria)
• Chest X-Ray to evaluate pulmonary disease
• Thyroid function, Renal Function, Serum Electrolytes
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Atrial Flutter
Atrial Tachycardia
AVNRT (Atrio Ventricular Nodal Reentry Tachycardia)
PSVT (Paroxysmal Supra Ventricular Tachycardia)
WPW syndrome
Digoxin Toxicity
Cardiac Ischemia secondary to Rapid Ventricular rate
Hyperthyroidism, Pulmonary Disease
Diagnosis
of AF
Chronic
Atrial Fib
New
Onset AF
Paroxysmal
Up to 7 d
Persistent
> 7 days
Permanent
CV failed
• Paroxysmal AF: if it terminates spontaneously in fewer
than 7 days (often in <24 h).
• Persistent AF: when it terminates either spontaneously
after 7 days or following cardio version.
• Permanent AF: It persists for more than one year, either
because cardio version has failed or because cardio
version has not been attempted
Paroxysmal
Permanent
New Onset
Persistent
• Is it primary or secondary – A thorough evaluation is a must
• Structural heart disease and age are most important factors
• AF without structural heart disease is “Lone Atrial Fibrillation”
• MVD, AVD, HT, CAD, LVD, DCM, HCM, PE, ASD,  Thyroid fun
• Coffee, Tobacco, Ethanol, Stress, Fatigue – may trigger AF
• No organic HD, No WPW – Address the precipitating factors
• Observe for recurrence of AF
• If HD is underlying – AC, Rate control, Rhythm control needed.
• If no underlying HD – Rest, Sedation, Digitalis for the attack
• Hemodynamic compromise – immediate cardioversion
• Hemodynamically stable – Rate control, AC & Rhythm control
• Beat Blockers, CCB, Flecainide, Propafenone – IV may be given
• No structural Heart Disease - Flecainide, Propafenone preferred
• Amiodarone is in patients with HF, DCM, structural HD
• Sotalol in CAD and HT without LVH
• Catheter ablation and MAZE procedure in refractory cases
• Ventricular rate control and Anticoagulation are the best
• Cardioversion needed only if hemodynamic benefit is seen
• Either pharmacological or DC cardioversion can be tried
• Usually no more than one attempt of DC cardioversion
• Reverting to sinus rhythm didn’t give extra benefit (AFFIRM)
• Long term anticoagulation is a must – risk benefit titration
• Catheter ablation to HIS bundle with pace maker implant
• Only if refractory as it makes the pt pace maker dependent
Relief of Symptoms & Prevent recurrence, HF
Prevention of Systemic Thromboembolism
Tachycardia induced Myocardial Remodeling
Rate
Control
Rhythm
Control
Warfarin
(INR 2-3)
Cardio
Version
Anticoagulated
INR 2-3 for > 3 wk
Hemodynamically
Stable
Not
Anticoagulated
INR < 2 for 3 wks
New onset AF
Hemodynamically
Unstable
Cardio Version
Cardio version
Anticoagulated
INR 2-3 for > 3 wk
Rate Control
OP follow up in
24 to 48 hours
Warfarin and
Rate control
Not Anticoagulated
OP follow Up
Or INR < 2 for 3 wk
TEE/ Cardio Version
Recurrent AF
Minimal
Symptoms
Disabling
Symptoms
Warfarin
Rate Control
Warfarin
Rate Control
No Prevention
No AAD Rx
AAD Rx for
Prevention
Integration of several factors
Age of the patient
Degree of Symptoms
Rate
Rhythm
Likelihood of success of CV
Status of anti coagulation
Presence of atrial thrombus
Presence of co-morbidities
AFFIRM Trial
Rhythm
RACE Trial
Younger Patients - Rhythm
Co-morbid older Pt - Rate
Rate
Anti coagulation a must
Warfarin
INR – above 2 - Therapeutic
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Atrial fibrillation is a powerful risk factor for stroke
The most important treatment in AF is anticoagulation
Acute cardio version is risky without anticoagulation
This risk is same for electrical or pharmacologic CV
TE risk increases if AF is of > 48 hours
Effective Anticoagulation reduces the risk by three fold
Initiation of AC can be done with Heparin or LMWH
Oral direct thrombin inhibitor (Ximelagatran) no INR
Male Gender, Advancing Age
Rheumatic Valvular Heart Disease (RVHD)
Diabetes, Hypertension , CAD, LV Dysfunction
Heart Failure; Prior history of TIA/Stroke
One Point
• Cardiac Failure
One Point
• Hypertension
One Point
• Age more than 75
One Point
• Diabetes
Two Points
• Stroke or TIA, STE
CHADS2 Score (points)
Adjusted Stroke Incidence % per year
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1.9
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2.8
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4.0
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5.9
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8.5
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12.5
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18.2
Non valvular Atrial Fibrillation Rx with anticoagulation
Risk Factor Stratification Risk Factors to be Ascertained
High Risk Factors
Prior Stroke/TIA or STE Event
Moderate Risk Factors
Age >75, HF, HT, EF <35%, DM
Other Risk Factors
Female, CAD,  Thyroid, < 75
Non valvular Atrial Fibrillation Rx with anticoagulation
Risk Category
Recommended Treatment
Age < 65; No RF
Aspirin 325 mg/day
Age 65-75, DM, CAD
1 RF – Give Aspirin 325
2 RF – Warfarin (INR 2.0 to 3.0)
Age > 75, HT, LVD,MVD,
Pr HV, Stroke, TIA, PE or
More than 2 Moderate RF
Warfarin (INR 2.5 to 3.5)
Atrial Fibrillation Treatment with Anticoagulation
1.5% in < 60 yrs
23.5% in > 80 yrs
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AF is associated with risk of  TE – Stroke, TIA, Perph E
Anticoagulation with Heparin and Warfarin to  TE
Anticoagulation – risk of fatal bleeding – monitor INR
Anti platelet Rx with Aspirin, Clopidogrel to  TE
Use the CHADS2 score to stratify the patients
CHADS2 Score of zero need only Aspirin or Clopidogrel
CHADS2 score of 3 or above need Warfarin / Heparin
Score of 1 or 2, see H/o stroke, TIA, CAD, HT, Females
Anti Coagulant Trade Name Dose
Route
Monitoring
Heparin
Beparine
5000 I.U
S.C or I.V
aPTT
LMWH
Fluxum
0.3 to 0.5 ml
S.C given OD
None
Warfarin
Uniwarfin
10-15 mg
Oral daily
INR
Nicoumulone
Acitrom
8 mg / 2-4 mg
Oral daily/alt
INR
Phenindione
Dindivan
200mg / 100mg Oral daily
INR
Ximalagatran
Dire Thr Inh
Ongoing trials
None
Liver toxicity
• History of bleeding
(2 points)
• Hepatic or renal disease
(1 point)
• Alcohol abuse (1 point)
• Malignancy (1 point)
• Older age (>75 y) (1 point)
• Aspirin therapy (1 point)
• Reduced platelet count
or platelet function (1 point)
• Hypertension (1 point)
• Anemia (1 point)
• Genetic predisposition
(1 point)
• Excessive fall risk (1 point)
• Patient of stroke (1 point)
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Zero points - 1.9%
One point - 2.5%
Two points - 5.3%
Three points - 8.4%
Four points - 10.4%
Five or more points - 12.3%
• Bleeding risk outweighs the benefit, no Anticoagulation
• Pregnancy (specially 1st trimester), Elective surgery
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Control of ventricular rate is a critical a component
Rate-controlling agents act by  AV nodal refractoriness
 blockers and CCBs are first-line rate control agents
Given either I.V. or orally depending on the need
ROAD patients we need to exert caution with Bs
HR < 80 at rest; < 110 with exertion (6 min walk test, TMT)
Digoxin is rarely used as monotherapy
Some what useful in pts with HF and LV dysfunction
Amiodarone - Class II a recommendation for rate control
CCBs
DLZ, VPM
Digoxin
Blockers
Rate
Control
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For rapid rate control I.V. drug should be used
IV CCBs (DLZ, VPM),  Blocker (Metoprolol, Esmolol)
Diltiazem is preferred because of least side effects
For pts with  sympathetic tone – Esmolol is preferred
AF with heart failure; Digoxin is the choice; Not a CCB, BB
Digoxin has delayed onset of action; Not effective rapidly
Amiodarone is the choice in AF with CHF and  BP
Flecainide or Amiodarone in AF with pre excitation
CCB and digoxin are contraindicated in pre excitation
• Rate and Rhythm control yield similar results (AFFIRM)
• Young pts who remain symptomatic after rate control
• In whom rate control drugs are contraindicated
• Who do not tolerate rate control drugs
• Rate and Rhythm control drug combination cab be used
• Class I c (Flecainide, Propafenone) are contraindicated in CAD
• In CAD and Diastolic Heart Failure – Amiodarone is the choice
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Sinus Rhythm requires Rx of CV Risk factors,  Thyroid
Anti arrhythmic drugs restore Sinus Rhythm
Amiodarone is safe and effective to restore SR
Its adverse effects may be a problem in some
Sotalol is efficacious for maintenance of sinus rhythm
Requires monitoring of the QT interval & electrolytes
It is contraindicated in pts with structural heart disease
Catheter ablation is an alternative to drug therapy in
symptomatic pts without structural heart disease
AA Drug
Class
Dosage
Indication
Remarks
CI / SP
Amiodarone
III
200-400 OD
Structural HD, HF
Other ADR
Brady, Sparf
Dofetilide
III
125-250 g BD
Structural HD, HF
Non pediatric
CKD, QT 
Sotalol
III
80-160 BID
No Structural HD
Maintenance
QT , TdP
Flecainide
Ic
50-150 BID
No Structural HD
PIP- Lone AF
CAD, BB
Propafenone
Ic
150-300 OD
No Structural HD
PIP- young pts
CAD, BB
Dronedarone
All
400 mg BID
No Structural HD
Heart Failure
QT , Brady
AFFIRM, CAST, CTAF, SAFE-T, RACE
• Elective cardioversion and emergency cardioversion
• Electrical and chemical cardioversion (Ibutilide IV CIII)
• Most successful when initiated within 7 days of onset
• Acute cardioversion in hemodynamically unstable
• Pharmacological cardioversion no sedation or anesthesia
• But, risk of ventricular tachycardia serious arrhythmia
• Direct current (DC) energy cardiovertor is used
• Maintain serum potassium in upper normal range
• Hemodynamically unstable with AF
• Severe dyspnea or chest pain with AF
• Patients with pre-excitation in ECG with AF
• Non responders of AF with rate control therapy
• Pts without any valvular or functional heart abnormality
• DC cardioversion - electrical current that is synchronized
to the QRS complexes; monophasic or biphasic waves
• The required energy for cardioversion is usually 100-200 J
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In short duration atrial fibrillation
In whom the left atrium is not significantly large
The success rate of cardioversion exceeds 75%
Patient is sedated or anesthetized during CV
Embolization is the most important complication of CV
So, thrombus in the atria must be ruled out by TEE
Or, Warfarin must be given for 4 weeks before CV
Patient must receive Warfarin for at least 4 wks after CV
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Thromboembolism after CV
Pulmonary edema
Hypotension
Myocardial dysfunction
Skin burns
ST- and T-wave changes on ECG
Elevated levels of serum cardiac markers
Synchronization of DC shock with QRS
prevents serious ventricular arrhythmias
• Electrical cardioversion is the most commonly used
• P-CV is used if direct-current (DC) cardioversion fails
or, in some cases, as a pre cardioversion strategy
• Pretreatment with Amiodarone, Flecainide, Ibutilide,
Propafenone, or Sotalol increases success of DC CV
• This is not a choice in the hemodynamically unstable
• Hemodynamically unstable patients
• Those with new onset atrial fibrillation
• Those with associated underlying heart disease
• Those who are in heart failure
• Patients older than 65 years
• Patients with suspected Acute Coronary Syndrome
• Other co-morbid medical problems
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Reducing the chance of atrial fibrillation recurrence
Reducing atrial fibrillation-related symptoms
Control of ventricular rate
Reducing risk of TE and Stroke
Management of CV risk factors to reduce the AF
recurrence and related morbidity and mortality
• Anticoagulation is a must for all except ‘lone AF’
• Younger pts rhythm control, older ones rate control
• AF begets AF, Sinus Rhythm begets Sinus Rhythm
• Atria are transected and resutured to  the critical mass
• Surgical MAZE procedure is an attractive procedure
• Catheter Ablation is the widely used procedure
• Compartmentalization with continuous ablation lines
• Catheter ablation of focal triggers of atrial fibrillation
• AV node ablation & insertion of a permanent pacemaker
• Percutaneous closure of the left atrial appendage to  TE
• Post Ablation Anti Arrhythmic Drug therapy
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Atrial Fibrillation is the most common arrhythmia
Evaluate for any underlying structural heart disease
Classification patients and risk stratification for Rx
Thrombo embolism is the main threat in a pt of AF
Age is a very strong risk factor for AF as well as STE
Anticoagulation with Warfarin is the main stay of Rx.
Rate control with -B and CCBs is a must in all
AAD for rhythm control only in selected chronic AF
Cardioversion, Catheter Ablation, MAZE in selected pts