Transcript Atrial Fibrillation

Atrial Fibrillation
Outline
•
•
•
•
•
•
•
Epidemiology
Signs and Symptoms
Etiology
Differential Diagnosis
Diagnostic Tests
Classification
Management
Epidemiology
• Most frequently diagnosed arrhythmia
• Affects 2.3 million people in the US
• Affects 1/136 people in the US
– Columbus population 769,360 (2009)
• Would expect to see 5600 pts/year!
• Incidence increases with age
Signs and Symptoms
•
•
•
•
•
Palpitations
Weakness
Dizziness
Reduced exercise capacity
Dyspnea
• Asymptomatic
Etiology/Risk Factors
•
•
•
•
•
•
•
•
Structural heart disease
Chronic lung disease
Key Point
MI is a very rare
Pneumonia
cause
of
Afib!
Hyperthyroidism
Think twice before doing a ROMI
Alcohol use
Pulmonary embolism
HTN
Pericarditis
Differential Diagnosis
• Narrow Complex Tachycardias
– Atrial Fibrillation
– Atrial Flutter
SVT is a category, not a
– AVNRT
diagnosis!
– AVRT
– Atrial tachycardia
– Sinus tachycardia
– Multifocal atrial tachycardia
Classification
•
•
•
•
Paroxysmal: terminates in < 7 days
Persistent: fails to terminate within 7 days
Permanent: > 1 year
Lone: Individuals without structural heart
disease, < 60 yrs old
Diagnostic Testing: EKG
Irregularly
Irregular
Narrow
Complex
Rapid
Ventricular
Rate
Diagnostic Testing: TTE
• To assess for structural heart disease
– EF
– Wall motion
– Dilation/Hypertrophy
– Size of right and left atrium
– Valvular disease
– Pericardial disease
Chest X-Ray
• Look for emphasema/COPD
• Cardiac borders
• Pneumonia
Rush Center for Congenital and
Structural Heart Disease
Management
•
•
•
•
Rate Control
Rhythm Control
Anticoagulation
Unstable patients
Rate Control
• Why is rate control important?
– Ischemia, MI, hypotension can occur
– Long term: Cardiomyopathy
• Goals
Key Point
– Rest HR < 80 bpm
– 24 Hour (Tele/Holter) < 100 bpm average
– HR < 110 in 6 minute walk
Rate Control (con’t)
• Medications
– Metoprolol / Esmolol: IV or Oral
– Diltiazem: IV or Oral
– Verapamil: Oral Only
– Digoxin: Patients with hypotension
– Amiodarone: Also for rhythm control
Rhythm Control
• Indications
– Symptoms of a-fib persistent
– To avoid long term anticoagulation
– Bleeding risk
– Personal preferenance
Rhythm Control (con’t)
• Synchronized DC cardioversion
– Emergencies/Hemodynamic instability
– Greater efficacy than medications
• Pharmacologic cardioversion
– If AF < 7days – dofetilide, flecainide, ibutilide,
propaferone or amiodarone
– If AF > 7 day – dofetilide or amiodarone
Rate or Rhythm Control?
• Affirm Study: Rate versus rhythm control
– No difference in incidence of stroke
– Trend towards lower mortality in the rate
control group
– See article
– This is STILL a controversial topic!
Anticoagulation and
Cardioversion
• Afib < 48 hours:
– Cardioversion (CV)
– No anticoagulation
indicated
• Afib > 48 hours:
– Anticoagulate for 3-4
weeks before CV
– OR get TEE
– Anticoagulate for 1
month after CV
Anticoagulation – Long Term
• Risk of CVA determined by CHADS2
score (CHF, HTN, >75, DM, Previous CVA
x 2)
Score
Annual Stroke Risk %
0
1.9
1
2.8
2
4.0
3
5.9
4
8.5
5
12.5
6
18.2
Key Points
Most patients, can wait
48 hours before
starting
0-1 probably don’t
need anticoagulation
5-6 should be bridged
with heparin/LMWH
Management – Unstable
Key Point
Unstable: A-fib associated with Hypotension
Synchronized electric Cardioversion
immediately
Key Points
• MI is a rare CAUSE of a-fib
• Rate control must be achieved during
exercise, not just at rest
• Not every patients needs to bridge with
heparin
• Unstable patients should immediately be
cardioverted
Questions?