atrial fibrillation current management strategies
TRANSCRIPT
Atrial Fibrillation
Current Management Strategies
Overview
• 25% will develop AF during lifetime• 4% above 60• 8% above 80• Total sufferers to double by 2050• Doubles annual risk of death
(Framingham)• 5% annual risk of stroke
Definitions
• Paroxysmal AF– Under 7 days– 2 or more episodes
• Persistent AF– 7 days to 1 year
• Permanent AF– Over 1 year with/without intervention– Accepted for rate control
Pathophysiology
Supraventricular ectopic focus with permissive atrial substrate
Younger
Myocytes in pulmonary veinsDrugs and alcoholMetabolic abnormalitiesElectrolyte abnormalitiesSepsis
Older
LVH/aortic stenosisAtrial ischaemia and IHD
Mitral stenosis/incompetence
HypertensionCatecholamine drive
Sepsis
Two Considerations
• Reduce ventricular rate– Cardiovert– Slow
• Prevent thromboembolism– Cardiovert – Anticoagulate
Treatment Strategies
Rhythm Control
YoungerFirst presentation
Underlying cause treatedSymptomaticHeart Failure
Rate Control
OlderCoronary artery disease
Contraindications to cardioversion
Previous failure
Paroxysmal PermanentPersistent
Rhythm Control
Rate ControlFailure
Symptoms Persist
Rhythm Control – Paroxysmal AF
• All need assessment for anticoagulation
• May need cardioversion (but aim to avoid)
• Pill in pocket may be appropriate (flecanide)
• Standard beta-blocker first line (bisoprolol)
• If failure:– CAD – Sotalol– LVD – Amiodarone
Rhythm control – Persistent AF
Onset < 48 hours
Electrical
Outpatient Management
Emergency Department
Chemical
Amiodarone
Flecanide
Heparinise
Sotalol or Amiodarone
Failure likely?
Warfarinise
Rate Control
Rate control – Persistent or Permanent
• All patients need assessment for anticoagulation
• Aim for rate under 100 (may need nothing)
• Beta-blocker of calcium channel antagonist
• Add digoxin if further control necessary
Thromboembolism
• Ineffective atrial contraction• Venous pooling in atrial appendage• Embolism
CHAD2Vasc
• Congestive Cardiac Failure• Hypertension• Age > 75 (2) > 65 (1)• Stroke/TIA/DVT/PE (2)• Vascular disease• Diabetes• Female 0 – Low risk
1 – Moderate risk
> 2 high risk
European Society of Cardiology
High Risk
CVATIAVTE
Medium Risk
> 75HTN
EF < 35%DM
No Risk
Warfarin Aspirin
Ablation/MAZE procedure
• 1:1000 death• 1:50 complications• 60% success
Case 1
• 40, fit and healthy, normal ET, normal resting ECG
• Onset AF@135bpm 24 hours ago, first event• Haemodynamically stable• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then Aspirin 75mg
Pill in pocket
Flecanide 300mg
Case 2
• 60, on carbimazole and bendroflumethiazide
• AF for 24 hours, otherwise normal examination
• All bloods normal including TFTsAnticoagulant?
Maintenance?
Cardioversion?
Heparin then warfarin
Bisoprolol
Electrical (not amiodarone)
Case 3
• 28 fit and well, onset AF 3 hours ago• Mild symptoms, examination normal• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then aspirin
Pill in pocket
Not today, return starved tomorrow
Case 4
• 89, SOB, tachycardic, febrile, cough• Raised WCC and ARF and
hypokalaemia
Anticoagulant?
Maintenance?
Cardioversion?
Probably
Review prior to discharge
Not until treated
Case 5
• 80, hypertensive, smoker with COPD• Incidental finding, symptom free• Rate 110bpm
Anticoagulant?
Maintenance?
Cardioversion?
Warfarin
Diltiazem
No
Case 6
• 50, AF 8 hours, ejection systolic murmur
• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then aspirin
Bisoprolol
Amiodarone
Case 7
• 50, AF 8 hours, ejection systolic murmur
• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then aspirin
Bisoprolol
Amiodarone