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Atrial Fibrillation “Pearls and Pitfalls”. Sean P. Mazer, MD October 17, 2009. Conflicts of Interest. Consultant for St. Jude Medical Consultant for Medtronic. Case 1.

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atrial fibrillation pearls and pitfalls

Atrial Fibrillation“Pearls and Pitfalls”

Sean P. Mazer, MD

October 17, 2009

conflicts of interest

Conflicts of Interest

Consultant for St. Jude Medical

Consultant for Medtronic

case 1
Case 1
  • 50 yo man with HTN with presents to your office with fever, myalgias and shortness of breath. He is coughing up clear phlegm. He has sick contacts at home.
  • He has a temp of 102, and room air sat of 93%
  • On exam he is wheezing and appears dehydrated.
slide4
Rx
  • He appears to have a URI with some degree of bronchospasm.
  • He is treated with bronchodilators
  • Two days later he is still feeling badly
  • You put him on an oral steroid taper.
  • 4 days later he is back this time with
    • Chest pain
    • SOB
    • Palpitations
work up
Work-up
  • Echo
  • TSH, CBC, BMP
  • Chest X-ray
  • Other steroid uses (injected steroids)

Follow-up

  • Atrial fibrillation disappears one week later
  • The following year palpitations return and he is diagnosed with atrial fibrillation again.
rx for paroxysmal atrial fibrillation
Rx for Paroxysmal Atrial Fibrillation
  • Beta blockers and Ca channel blockers (sometimes control event frequency)
  • Anti-arrhythmic drugs
    • First line therapy
      • Flecainide and Propafenone (Sodium channel blockers)
      • Sotalol (Potassium Channel blocker)
      • Efficacy is 40-50% reduction of atrial fibrillation events (wide range of outcomes)
    • Second line therapy
      • Ablation
  • Medication for life?
what s new 09
What’s New ‘09
  • Stereotaxis
    • No perforations
    • Ability to make a confluent line
    • Speed
  • Cryoballoon ablation
    • Electrical isolation of a vein in 1-2 lesions
    • Standardization
    • Speed
    • ?less ancillary damage than RFA
case 2
Case 2
  • 82 yo man presents with hematuria to the ED. He has no other complaints
    • PSA is normal, UA shows blood only
    • He is slightly anemic (Hct 36%), nl WBCs
    • CT urogram was normal
    • Urology recommends cystoscopy
  • PMHx: HTN only
  • Vitals: HR 140 BP 110/70
  • Cardizem drip started.
atrial flutter
Atrial Flutter
  • Regular arrhythmia
    • Flutter waves visible (CL 200-280ms)
    • V1- isoelectric component
    • III and aVF- downward continous
    • Difficult to rate control
    • Usually sustained until intervention (stable arrhythmia)
  • Pulmonary disease (DDimer)
  • Sleep apnea
treatment
Treatment
  • He underwent cystoscopy and fulguration of a bleeding bladder polyp.
  • He was started on heparin and coumadin
  • TEE confirmed the absence of left atrial clot
  • Ablation performed restoring sinus rhythm
atrial flutter ablation
Atrial Flutter Ablation
  • Even in the elderly
    • 97% success rate
    • 1/500 minor complication
    • Fewer medications, fewer readmissions, less CHF
  • VERY IMPORTANT
    • Atrial fibrillation occurs in 40-50% of these patients over 5 years.
    • Slow to stop warfarin even though AFL cured
case 3
Case 3
  • 80 yo woman fainted in the grocery store.
  • She was standing in line and began to feel warm.
  • She went and sat down beside the cashier.
  • She slumped over and was unresponsive for <20 seconds.
  • EMS arrived, she was feeling normal. Vitals were normal. She did not go to the hospital.
treatment19
Treatment
  • Realtime ECG monitoring as an outpatient reveals 5 second pauses during the daytime.
  • PPM implanted
  • No EEG, no MRI, no Holter, no carotid studies
  • No recurrence
case 4
Case 4
  • 72 yo man discharged home after TIA on aspirin and plavix
  • “aspirin failure”
  • Normal carotids, no CV history
  • CT scan did not show a stroke
  • Where did the TIA come from?
  • Real time ECG monitoring.
atrial fibrillation
Atrial Fibrillation

Up to 40% of strokes are caused by Atrial Fibrillation

anticoagulation risk reduction
Anticoagulation: Risk Reduction
  • Adjusted dose oral anticoagulation reduces risk of stroke by 62% (80% by on treatment analysis)
  • Maximum protection: INR 2.4 (60% of the time)
  • Elderly with risk of bleeding: INR 2 “reasonable”
    • Related to age, HTN, vasculopathy; microbleeds
  • Most trials required low risk of bleeding to enroll
  • Low risk: <1.5%/yr: no proven benefit
  • Intermediate risk: 1.5-5%/yr: divided opinion
  • High risk: >5%/yr Anticoagulation recommended
chads2
CHADS2
  • 2 points for prior stroke
  • 1 point for age, diabetes, congestive heart failure, age >75 and hypertension

Medicare pts

2006 ACC/AHA Guidelines for atrial fibrillation management

what s new in 09
What’s new in ’09?
  • Left atrial appendage occlusion
    • Pts with long term anticoagulation risk
    • ?Pts who don’t want warfarin
    • ?Anyone who has an ablation
    • ?Highest risk patients
  • Warfarin replacements
    • Only mechanical valve patients will be on warfarin within 2 years.
case 5
Case 5
  • 80 yo woman presents to the office with complaints of shortness of breath and insomnia. She says that her heart feels like it’s coming out of her chest.
  • Vitals at rest 120-30, BP 140/80, saturation 88%
  • Physical exam- JVP to jaw, scattered rales, 2+ edema.
workup therapy
Workup &Therapy
  • Echo
    • Stress test if EF<35% or chest pain
  • Holter 24 hours (on therapy)
  • Furosemide, potassium
  • Coumadin therapy (not to the ED for heparin)
  • Metoprolol, Cartia or digoxin?
  • Don’t forget Oxygen
digoxin
Digoxin
  • Combined analysis of the SPORTIF III and V trials
  • 7329 patients, 53% using digoxin
    • Mortality
      • 6.5% in the digoxin using group vs 4.1%
      • Hazard ratio 1.58, 1.53 after adjusting for baseline comorbidities
  • Affirm trial HR with dig use 1.42
  • Pro-arrhythmia, procoagulant

Olsson, B et al. Heart 94:191 (2008)

therapy
Therapy
  • 80% of pts require 2 agents for rate control.
  • Beta blockers and Calcium channel blockers combined most effective.
  • Rates of 90-100 during daytime, 70-80 during sleep.
  • Expect heart rates to be +20 BPM.
  • More aggressive=more PPM
  • Amiodarone is a poor rate control medication.
case 6
Case 6
  • 52 yo man presents to you for his first physical.
  • He mentions that he would like an ECG.
  • The rest of the exam is normal.
  • The ECG shows:
conduction defects
Conduction defects
  • RBBB
    • Most common conduction defect in humans
    • <10% lifetime risk of PPM
  • LBBB
    • 50% lifetime risk of PPM
  • Both require echo and cardiac work-up
  • First degree AV block?
family history
Family History
  • What did they die from?
  • How old were they?
  • Drowning?
  • Accidents?
  • Heart Attacks?
  • Pacemakers?
first degree av block
First Degree AV block
  • 7575 patients in the Framingham Heart Study had ECGs
  • 124 had PR intervals >200ms
    • 13 PR got longer
    • 26 with AV block

Cheng S et al. JAMA 301: 2571-25789 (2009)

who can you call
Who can you call?
  • NMHI EP clinic
    • Dr. Kathleen Blake, Dr. Jerry Arellano, Dr. Chris Wyndham, Dr. Ross Downey, Dr. Barry Ramo
  • Non-urgent
    • PSRs- JoAnne Lopez and Sandy Vallejos
      • 843-2864, 843-2599
      • Fax 505-843-2843
  • Urgent
    • Cell 505-401-6224
    • Fax 901-284-1888
    • Email seanm@nmhi.com