Atrial Fibrillation 16-May-10

Dr R V S N Sarma, M.D., M.Sc., FIMSA 1

Atrial Fibrillation
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
Its characterized by disorganized atrial electrical activity
Progressive deterioration of atrial electromechanical
function with several theories of abnormal activity
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ECG of Atrial Fibrillation
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 an typically irregular ventricular response
Irregularly irregular heart and pulse
Narrow QRS usually, reentrant pathway wide QRS
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ECG of Atrial Fibrillation Pathophysiology of AF
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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Symptoms of AF
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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Clinical Signs of AF
Irregularly irregular heart beat pulse-apex disparate
May or may not have tachycardia depends on AVN
Variable intensity of 1
st
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
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Atrial Fibrillation 16-May-10
Dr R V S N Sarma, M.D., M.Sc., FIMSA 2
Causes of Atrial Fibrillation
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
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Atrial Fibrillation
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.
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Investigations
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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Types of Atrial Fibrillation
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
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First Episode of Atrial Fibrillation
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.
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Paroxysmal Atrial Fibrillation
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
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Atrial Fibrillation 16-May-10
Dr R V S N Sarma, M.D., M.Sc., FIMSA 3
Chronic Atrial Fibrillation
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 didnt 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
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Anticoagulation
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
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Risk Factors for Stroke in AF
Male Gender, Advancing Age
Rheumatic Valvular Heart Disease (RVHD)
Diabetes, Hypertension , CAD, LV Dysfunction
Heart Failure; Prior history of TIA/Stroke
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CHADS
2
Scoring
Cardiac Failure One Point
Hypertension One Point
Age more than 75 One Point
Diabetes One Point
Stroke or TIA, STE Two Points
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CHADS
2
based Stroke Incidence
CHADS2 Score (points) Adjusted Stroke Incidence % per year
0 1.9
1 2.8
2 4.0
3 5.9
4 8.5
5 12.5
6 18.2
Non valvular Atrial Fibrillation Rx with anticoagulation
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Risk Stratification
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
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Atrial Fibrillation 16-May-10
Dr R V S N Sarma, M.D., M.Sc., FIMSA 4
Rx. Recommendations
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
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Prevention of Thromboembolism
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 CHADS
2
score to stratify the patients
CHADS
2
Score of zero need only Aspirin or Clopidogrel
CHADS
2
score of 3 or above need Warfarin / Heparin
Score of 1 or 2, see H/o stroke, TIA, CAD, HT, Females
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Rate Control
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
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Rate Control
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
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Rhythm Control
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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Rhythm Control
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
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Atrial Fibrillation 16-May-10
Dr R V S N Sarma, M.D., M.Sc., FIMSA 5
AADs in AF
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 I c 50-150 BID No Structural HD PIP- Lone AF CAD, BB
Propafenone I c 150-300 OD No Structural HD PIP- young pts CAD, BB
Dronedarone All 400 mg BID No Structural HD Heart Failure QT , Brady
25 AFFIRM, CAST, CTAF, SAFE-T, RACE
Cardioversion
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
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Cardioversion
Hemodynamically unstable 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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Long Term Management
Reducing the chance of atrial fibrillation recurrence
Reducing atrial fibrillation-related symptoms
Control of ventricular rate, risk of STE 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
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Surgical Therapy
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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Take Home Points
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
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