Transcript Treatment of Atrial Fibrillation

Treatment of
Atrial
Fibrillation
M Samson – PGY-2
Riverside Campus
July 17, 2015 Academic Day
Outline
• Definitions
• A Fib in the acute setting
o Electrical Cardioversion
o Chemical Cardioversion
• Chronic Treatments
o Rate Control
o Rhythm Control
• Stroke Prophylaxis
o Risk stratification
o VKA
o NOACs
Definitions
• Paroxysmal AF – AF that terminates spontaneously
or with treatment within 7 days of onset. Episodes
may recur with variable frequency.
• Persistent AF – Lasting more than 7 days
• Long-Standing Persistent – more than 12 months
• Permanent – When the patient and clinician make
a joint decision to stop further attempts of restoring
sinus rhythm
• Non-Valvular A fib – AF in the absence of rheumatic
valve disease, prosthetic valve, or mitral valve
repair.
A Fib in the ED
• Treatment depends on several factors. The 2 most
important ones are:
o 1) hemodynamic compromise
o 2) time of onset
Acute Onset A Fib
Hemodynamic
Instability
No
Yes
Electrical
Cardioversion.150 J
synchronized.
Anticoagulate for 4
weeks
Onset
<48hrs
Yes
Offer rate or rhythm
control. Electrical
Cardioversion is
appropriate.
No
Rate Control.
Anticoagulate
for 3 weeks
before rhythm
control.
Acute Onset A Fib ?anticoagulation
• If onset is greater than 48 hrs offer heparin for
anticoagulation for subtherapeutic anticoagulation
or no anticoagulation. Continue heparin based on
risk stratification. Continue for at least 4 weeks.
• If onset is less than 48 hrs offer anticoagulation if 1)
stable sinus rhythm not restored within 48hrs, 2) there
is a high risk of recurrence 3) it is recommended
based on risk stratification.
Chronic Treatment
• Rate Control
• Rhythm Control
• Stroke Prophylaxis
Risk Stratification – Stroke
Vs Major Bleeding
• CHA2DS2-VASc – determines risk of stroke
• HAS-BLED – determines risk of major bleed
CHA2DS2-VASc
• C – (C)HF
• H – hypertension
• A – Age, 2 points if greater than 75, 1 if greater than
65
• D – diabetes
• S – 2 points for previous stroke or TIA
• V – peripheral vascular disease
• Sc – Sex category, 1 for female
Case 1 – Mr Couminda
• Mr. Couminda is a 60 y/o gentleman. He has been
to the ED on 3 occasions over the past yr and
treated for atrial fibrillation with cardioversion.
Today, he denies any palpitations, chest pains,
orthopnea, PND, headaches, visual disturbances,
claudication, erectile dysfunction or signs of
neuropathy. He has had no previous stroke or TIA
• You have been treating him for T2DM and HTN.
• His current medications are
o Perindopril 4 mg daily
o Amlodipine 10 mg daily
o Metformin 500 mg BID
• Exam:
o
o
o
o
o
BP 124/78, HR 66, O2 sat – 99% on RA
CVS – S1/S2 normal, regular rhythm, no murmur, no JVP, no carotid bruits
Resp – GAEB, no crackles
Abdomen – no masses, no abdominal bruits
Extremity – sensation intact to light touch, well perfused, edema present
• Investigations:
o ECG – normal sinus rhythm
o Bloodwork – CBC – WNL, Electrolytes – WNL, Creat 74, LDL 1.9, TSH 1.43,
A1c 6.0%
o ECHO – EF 60%. No valvular anomalies.
What is his CHA2DS2-VASc?
• A) 0
• B) 1
• C) 2
• D) 3
• E) 4
What is his CHA2DS2-VASc?
• A) 0
• B) 1
• C) 2 – CHF-0, H-1, A-0, D-1, S-0, VASc-0, Male
• D) 3
• E) 4
HAS-BLED
•
•
•
•
•
•
•
H – hypertension
A – abnormal renal or hepatic function
S - stroke
B – bleeding
L – labile INRs
E – elderly
D – drugs (antiplatelet, NSAIDs) or ETOH
• Do not withhold anticoagulation based on fall risk!
CHA2DS2-VASc
• If 0 – do not offer anticoagulation
• If 1 – consider offering ASA or anticoagulation
• If 2 or greater and non-valvular AF – offer
anticoagulation with VKA or NOAC
• If 2 or greater and valvular AF – offer VKA
VKA - Warfarin
• Target is INR of 2.0 - 3.0 with non-valvular AF and 2.0
– 3.0 or 2.5 – 3.5 with prosthetic valves depending
on type of prosthesis and which valve
• INR should be checked weekly after initiation and
at least monthly when stable
• If INR is very labile and GFR >15, consider changing
to NOAC
NOACs
• Dabigatran, Rivaroxaban, and Apixaban currently
indicated for stroke prevention in AF
• No INRs or monitoring except yearly renal function
• Need to be titrated in moderate renal impairment
and should not be used in severe renal impairment
• Should not be used in valvular AF
• Ne reversible agent available
• Yearly creatinine should be monitored
Cost – from Rx files
•
•
•
•
Warfarin – $15/month
Dabigatran - $110/month
Rivaroxaban - $100/month
Apixaban - $140/month
NOACs and Renal
Impairment
Rate Vs Rhythm
Rate Control
•
•
•
•
•
•
Persistent AF
Less symptomatic
Age >65
HTN
No history of HF
Past failure of
antiarrhythmics
Rhythm Control
•
•
•
•
•
•
Paroxysmal or new AF
More Symptomatic
Age <65
No HTN
HF exacerbated by AF
No past failure of
antiarrhythmic drugs
Rate Control
• Offer for patients with all types of AF unless:
There is a reversible cause
They have heart failure caused by AF (rhythm control may be more
appropriate)
New onset AF
A flutter and ablation is suitable
• Can use
o 1) standard beta-blocker (not sotalol),
o 2) Non-DHP Ca channel blocker.
o Consider 3) digoxin if they are sedentary.
• If decompensated heart failure – start with betablocker then add digoxin if beta blocker not
controlling rate adequately.
Goals of Rate Control
• Asymptomatic patients with preserved LV function <110 bpm.
• Symptomatic patients or LV dysfunction <80 bpm.
FYI - Dosages
Rhythm Control
• If greater than 48 hrs AF – anticoagulate for 3 weeks
before rhythm control
• Electrical Cardioversion is reasonable
• Pharmacological – propafenone, dofetilide,
flecainide, ibutilide are appropriate
• “Pill in a pocket” with propafenone or or flecainide
if they have used these drugs in a supervised
setting. Need to use in addition to beta-blocker or
Ca Channel blocker. For paroxysmal AF.
• Consider cardiology referral for ablation if
symptomatic and refractory to pharmacological
options.
Resources
Rx Files – 9th Edition