atrial fibrillation - meity ardiana, md, fiha.pdf
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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Meity Ardiana
Putri Rachmawati Dewi
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Atrial Fibrillation (AF) affects 1–2% of thepopulation, and this figure is likely to increase in thenext 50 years
The average age of patients between 75 and 85 years
AF is associated with a five-fold risk of stroke and athree-fold incidence of congestive heart failure, andhigher mortality.
Pre
vale
nce,
perc
ent
Age, years
women men
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Disorganised electrical and mechanical activity thatoriginates in the atria with an irregular response
Characteristics of AF :
ESC 2010
Heart Rate
• A : > 300 bpm• V : slow to rapid
Rhythm
Irregularly irregular
P-Wave
• No distinct P waves• Fibrillatory
Fibrillationwaves
Irregular R-Rinterval
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Underlying Etiologies of Atrial Fibrillation
AHA 2014
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Classification of AF
ESC 2010
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
1. Focal Mechanisms
2. The multiple wavelet hypothesis
The pulmonary veins (PVs) have astronger potential to initiate andperpetuate atrial tachyarrhythmias
AF is perpetuated by continuousconduction of several independentwavelets propagating through the atrialmusculature
Markides, 2003; Iwasaki 2011
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
All patients History
Physical examination
ECG
Echocardiogram
Thyroid function
Selected patients
Holter monitor
Invasive procedure
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Symptoms vary greatly among individuals andinclude: anxiety, palpitations, dyspnea, dizziness,chest pain, and fatigue/weakness, irregular heartrate (Porth, 2005).
EHRA = European Heart Rhythm Association
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Physical examination
Irregular pulse, pulsus deficit
valvular disease,
Exophthalmos
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
NICE Guideline 2014
Transthoracic Echocardiography(TTE)
TransoesophagealEchocardiography
(TOE)• Baseline echocardiogram is
important for long-termmanagement
• Rhythm-control strategy is beingconsidered
• High risk or a suspicion ofunderlying structural/functionalheart disease
• Refinement of clinical riskstratification for antithrombotictherapy is needed
• When TTE demonstrates anabnormality that warrants furtherspecific assessment
• TTE is technically difficult and/orof questionable quality and wherethere is a need to exclude cardiacabnormalities
• TOE-guided cardioversion isbeing considered
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
ESC 2010
GOALS• Hemodynamic
stabilization• Ventricular
rate control• Prevention of
emboliccomplication
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Rate Control
AHA/ACC/HRS Atrial Fibrillation Guideline 2014
ESC Guideline 2010
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Rate Control AgentsDrug Classes Drug Loading Dose Maintenance Dose
Calcium ChannelBlockers (non-dihydropyridine)-initial DOC
Diltiazem 10 mg IV over 2minutesCan repeat up to 20mg IV
30 mg PO q6 hrs(can transition tolong acting)Can use 10 mg IVq6 hrs prn
Beta Blockers-initialDOC
Metoprolol 5 mg IVP q5min x3doses
25 mg PO BID, canuptitrate to 100mgPO BID
OtherDigoxin 0.5 mg IV loading
dose0.25mg IV in6 hrs0.25mg IV 6hrs after
0.125 mg PO QD
Other Amiodarone 150 mg IV/10 min1mg/minx 6 hrs0.5 mg/min x 18hrs
100-200 mg PO QD
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Rhythm control
ESC 2012
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
RATECONTROL
RHYTHMCONTROLVS
THE TRIALS• AFFIRM STUDY (2002)• RACE (2002)• PAF (2000)• STAF (2003)• HOT CAFÉ (2004)• RACE II (2010)
No differences in quality of life withrhythm control compared with rate control
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
RATECONTROL
RHYTHMCONTROLVS
• Persistent AF• Less symptomatic• Age ≥ 65 years old• Hypertension• No history of HF• Previous failure of
antiarrhytmic drug• Patient preference
• Paroxysmal AF or newlydetected AF
• More symptomatic• Age < 65 years old• No hypertension• HF clearly exacerbated
by AF• No previous failure of
antiarrhytmic drug• Patient preference
Frankel, 2013
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Antithrombotic management
CHA2DS2-VASc : congestive heart failure, hypertension, age ≥75 ,diabetes, stroke vascular disease, age 65–74, and sex category(female)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
ESC 2012 Atrial FibrillationGuidelines Update: Risk Assessment
Score CHA2DS2-VASc Risk Anticoagulation Considerations0 Low Aspirin (81-325 mg) daily or none
1 Moderate Aspirin daily or warfarin (INR to 2.0-3.0)or dabigatran (Pradaxa) or rivaroxaban(Xarelto) or apixaban (Eliquis), dependingon factors such as patient preference
2 or greater Moderate orHigh
Warfarin (INR 2.0-3.0) ordabigatran (Pradaxa) orrivaroxaban (Xarelto) or apixaban(Eliquis)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Importance of the HAS-BLED Score
Hypertension (> 160 mm Hg systolic) 1
Abnormal renal or hepatic function 1-2
Stroke 1
Bleeding history or anemia 1
Labile INR (TTR < 60%) 1
Elderly (age > 75 years) 1
Drugs (antiplatelet, NSAID) or alcohol 1-2
High risk (> 4%/year) > 4Moderate risk (2-4%/year) 2-3Low risk (< 2%.year) 0-1
Pisters R, et al. Chest 2010; 138: 1093.Lip GYH, et al. J Am Coll Cardiol 2010; 57: 173.
Weight (points)
Risk Score for Predicting Bleeding inAnticoagulated Patients with Atrial Fibrillation
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Flowchartanticoagulation
therapy
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
AHA/ACC/HRS Atrial Fibrillation Guideline 2014
ESC Guideline 2010
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Limitation of Warfarin
Slow onset of action
Genetic variation in metabolism
Multiple food and drug interactions
Narrow theurapeutic index
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
New Oral Anticoagulants (NOACs)
Dabigatran Rivaroxaban Apixaban
• RELY trial• Direct thrombin
inhibitor• 110 mg b.i.d and
150 mg b.i.d doses
• ROCKET-AF trial• Direct factor Xa
inhibitor• 20 mg once a day
• AVERROES trial• ARISTOTLE trial• Direct factor Xa
inhibitor• 5 mg b.i.d. with a
dose adjustmentto 2.5 mg b.i.d
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Comparison Overview of NewAnticoagulants with Warfarin
Features Warfarin New Agents
Onset Slow Rapid
Dosing Variable Fixed
Food effect Yes No
Drug interactions Many Few
Monitoring Yes No
Half-life Long Short
Antidote Yes No
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
The technique of ablation :To target individual ectopic withinthe PV to circumferentialelectrical isolation of the entirePV musculature
Catheter ablation should bereserved for patients withAF which remains symptomaticdespite optimal medical therapy,including rate and rhythm control.
Ablation
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Quality of life and exercise capacity are impaired inpatients with AF.
Patients with AF have a poorer quality of lifecompared with healthy controls, the generalpopulation, or patients with coronary heart diseasein sinus rhythm.
Hospitalisation can be limited to highly symptomaticpatients, those with structural heart disease, had anembolic event or are at high risk ofthromboembolism, and patients with failure of ratecontrol in the emergency department
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Atrial fibrillation (AF) is the most common sustainedcardiac arrhythmia, occurring in 1–2% of the generalpopulation.
AF confers a 5-fold risk of stroke, and one in five of allstrokes is attributed to this arrhythmia.
AF is defined as a cardiac arrhythmia with the followingcharacteristics: The surface ECG shows ‘absolutely’irregular RR intervals , there are no distinct P waves onthe surface ECG, the atrial cycle length (when visible), isusually variable.
The management of AF including the rate controlstrategy, rhythm control strategy, cardioversion andantithrombotic therapy
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Procedures: Ablation A catheter is inserted into the femoral artery to
the area of heart muscle where there's anaccessory (extra) pathway.
The catheter is guided using fluoroscopy. The physician is able to see the exact area on the
heart that is causing the accessory pathway Radiofrequency energy is transmitted to the
pathway and destroys the selected heart musclecells in a very small area (about 1/5 of an inch).
(American Heart Association, 2010).
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
ESC 2012