atrial fibrillation

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ATRIAL FIBRILLATION Dr SYED RAZA MD,MRCP(UK),CCT(UK),MESC,Dip.Card(UK),FCCP Consultant Cardiologist

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The Commonest Arrhythmia

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  • 1. ATRIAL FIBRILLATIONDr SYED RAZA MD,MRCP(UK),CCT(UK),MESC,Dip.Card(UK),FCCPConsultant Cardiologist

2. OBJECTIVES Introduction Classification Burden of the problem Diagnosis Management 3. What is it ? Abnormal electrical wavelets originate fromleft atrium Propagating in different directions Disorganized atrial depolarisation withouteffective atrial contraction 4. DIAGNOSIS Pulse palpation 12 lead ECG Holter monitoring Others Echocardiogram, CXR TFT, Electrolytes, Clotting, LFT,CBC 5. ECG Diagnosis On ECG p waves are absent and RR interval isvariable. f waves 350-600 beats /min. ventricular response is grossly irregular at100-160 beats /min. Rate : No. of R waves x 10 ( 6 sec strip) 6. Prevalance 2.2 Million people in the US 6.5 cases/1000 examinations 4% > 60yrs 8 % > 80 yrs 25% of individuals aged 40 yrs and older willdevelop AF in their life time. 7. Prevalence of AF in the Renfrew-Paisley studyCohort of men and women aged 4564 years (n = 15,406)Reproduced with permission of the BMJ Publishing Group from Stewart S et al, Heart 2001: 86:516-21 8. Clinical events (outcomes) affected by AFOutcome Parameter Relative change in AFpatients1.Death 1.Death rate is doubled2.Stroke2.Stroke risk increases 5times3.Hospitalisation 3.More frequent4.Quality of life and 4.Can be markedlyexercise capacity decreased5.LV function 5.Tachycardiomyopathy/heart failure 9. Classification of AFTerminologyClinical featuresInitial event (first SymptomaticRhythm/Ratedetected episode)Asymptomatic Onset unknownParoxysmal Spontaneous terminationRhythm 80 yrs : 3 yrsWith AF< 60 yrs : 3%> 80 yrs : 30% 22. Lip Y, et al. Chest 2010, 137(2):263 23. How do we determine stroke risk ? 0 points low risk (1.2-3.0 strokes per 100 patient years) 1-2 points moderate risk (2.8-4.0 strokes per 100 patient years) > 3 points high risk (5.9-18.2 strokes per 100 patient years) 24. Atrial fibrillation 2009 Target INR 2-3 25. ACC AHA HRS Afib Focused Update(Dabigatran), March 2011 Non-inferior to warfarin re thromboembolism (afib) Caution when CrCl < 30ml/min Increased dabigatran levels with amiodarone, verapamil Half life 12-17 hours No reversal re hemorrhage dialysis Coagulation testing ??? aPTT, dilute thrombin time 26. Who should remain on warfarin? Patient already receiving warfarin and stable whose INRis easy to control If dabigatran, rivaroxaban, apixaban not available Cost If patient not likely to comply with twice daily dosing(Dabigatran, Apixaban) Chronic kidney disease (GFR < 30 ml/min) 27. Bleeding Risk Assessment of bleeding risk should be part ofthe clinical assessment of AF patients prior tostarting anticoagulation Antithrombotic benefits and potentialbleeding risks of long-term coagulation shouldbe explained and discussed with the patient Aim for a target INR of between 2.0 and 3.0 Forms of monitoring include point of care ornear patient testing and patient self-monitoring 28. From Hart RG, et al. Stroke. 2005;36:1588 29. RF ABLATION THERAPY 30. Substrate for Substrate forTriggering eventsinitiationperpetuation 31. When to consider ablation? Antiarrhythmic therapy ineffective Antiarrhythmic therapy not tolerated Symptomatic afib 32. Others in whom ablation may be a first strategy Patient very symptomatic in AF and refusesantiarrhythmic drug therapy Young patient whose only effective antiarrhythmic drugis amiodarone Patient with significant bradycardia for whomantiarrhythmic drug therapy will require pacemaker 33. Summary AF is the commonest arrhythmia High prevalence Stroke is one of the most dreadfulcomplications . Different management strategies,