af afl blok 2.5.pdf

8/16/2019 AF AFL blok 2.5.pdf

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Fibrilasi Atrium,

patofisiologi & tatalaksana

Hauda el rasyid

Indonesian Heart rhytm society,

Divisi aritmia

Bagian kardiologi dan kedokteran vaskular

FK UNAND/RSUP DR. M. Djamil Padang 1


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SA NODE

• Spindle like

• 0,1 mm sub endocardium

• Subepicardial

• Ukuran …

• Muara SVC dan roof RA

• 90 % RCA, 10 % LCX

• Nervus vagus

• Simpatis dan parasimpatis

3


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His-Purkinje System

• The proximal portion of theHis bundle begins on theatrial aspect of the TV inthe membranous atrialseptum. The AV junctionrefers to the combination

of the AV node and theproximal portion of the Hisbundle

• The His bundle penetratesthe septum between theCFB and the septal leaflet

of the TV and splits intothe left and right bundlebranch systems


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The left bundle branch begins in themembranous septum directly belowthe right and noncoronary aorticcusps. It is composed of aposteromedial or left posteriorfascicle and the anterolateral oranterior fascicle. There usually is aseptal branch of the left bundle

The right bundle branch runs in theseptum as an insulated sheath until itreaches the base of the rightventricular papillary muscles. It thenfans out into the myocardium at theapex of the right ventricle (RV)

The His bundle has relatively sparseautonomic innervation

Blood supply emanating from boththe AV nodal artery and septalbranches of the left anteriordescending artery


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Clinical Events (Outcomes) Affected by AF

Camm AJ, et al. Guidelines for the management of atrial fibrillation. The Task Force for the Management of AtrialFibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010; 31(19):2369 – 2429


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AF Begets AF

AF causes changes in atrial electrophysiology

that promote AF maintenanceWijffels Circulation 1995; 92: 1954-68


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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:

Executive Summary JACC VOL. 64, NO. 21, 2014

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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:

Executive Summary JACC VOL. 64, NO. 21, 2014 28


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Management Cascade in AF



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Rate Vs Rhythm Strategy in AF


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Rate Vs Rhythm Control (AFFIRM)

Wyse DG, et. al. A comparison of rate control and rhythm control in patients

with atrial fibrillation. N Engl J Med. 2002;347:1825 – 1833.


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Rate Vs Rhythm Control



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Ventricular Rate Control

Principles of rate control strategies

•Adequate control of the ventricular rate cansignificantly improve symptoms and is critical to avoidtachycardia-mediated cardiomyopathy.

•Most patients managed using a rhythm controlstrategy also require medications for rate control.

•Hospitalization is rarely required to control ventricular

rate unless symptomatic.•Rate control for atrial flutter tends to be more difficultthan for AF.


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European Heart Journal (2010) 31:2369-2429


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Drugs to Control Ventricular


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Drugs to Control Ventricular

Response AV nodal blocking drugs include: Beta Blockers, CCB

(nondihydropyridine), and Digoxin Beta blockers are the most effective drug for rate control.

Digoxin provides poor rate control during exertion (sedentary or systolicHF)

Combination of beta blocker and either CCB or digoxin may be needed to

control the HR. Beta blockers and calcium channel antagonists should be used cautiously

in patients with HF.

AV nodal blocking drugs at doses needed to control the ventricularresponse can cause symptomatic bradycardia requiring pacemaker

therapy. Some antiarrhythmic drugs that are used to maintain sinus rhythm, such

as sotalol, dronedarone, and amiodarone, also provide some control ofthe ventricular response when patients are in AF.



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AVN Ablation


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AVN Ablation


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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:Executive Summary JACC VOL. 64, NO. 21, 2014

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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:Executive Summary JACC VOL. 64, NO. 21, 2014

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Conclusion

• Rate control can be first line strategy in

management of AF

• Beta Blocker, CCB and Digitalis are drug of

choises

• Sometimes AAD can be use for rate control

• If you cannot control ventricular rate using

medication --> AVN ablation+PPM


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af afl blok 2.5.pdf

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