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ATRIAL FIBRILLATION. NILOFAR RAHMAN, MD AMIT KUMAR, MD. DEFINITION A SVT with uncoordinated atrial activation with constant deterioration of atrial mechanical function

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atrial fibrillation

ATRIAL FIBRILLATION

NILOFAR RAHMAN, MD

AMIT KUMAR, MD

slide2

DEFINITION

  • A SVT with uncoordinated atrial activation with constant deterioration of atrial mechanical function
  • On EKGs it is defined by replacement of consistent P waves with rapid oscillations that vary in size, shape and timing ass. With an irregular RVR when AV conduction is intact.
slide4

CLASSIFICATION

  • PAROXYSMAL:Self terminates< 7 days, usu, within 24 hrs.
  • PERSISTENT: > 7 days, terminate spontaneously or by cardioversion
  • PERMANENT: > 1 YR, CV attempted or failed
  • LONE: Without any structural heart disease
associated diseases
ASSOCIATED DISEASES
  • HTN: 1.4 fold increase risk
  • CHD: when complicated by acute MI or heart failure
    • CASS trial: RR was 1.98 in 7 yrs
  • VALVULAR HEART DISEASE:
    • MS, MR, TR: 70% RISK
    • MS, MR: 52%
    • ISOLATED MS: 29%
  • HYPERTROPHIC CMP:
  • CONGENITAL HEART DISEASE
  • OTHERS: hyperthyroidism, PE, COPD, lupus myocarditis
    • OSA: reduced reccurence with treatment
slide6

CLINICAL MANIFESTATIONS

  • SYMPTOMATIC OR ASX EVEN IN SAME PT.
  • PALPITATION/CP/DYSPNEA/FATIGUE/LIGHTHEADEDNESS/SYNCOPE
  • EMBOLIC COMPLIC. OR HEART FAILURE
  • POLYURIA: ANP
  • ASS. RVR- CMP
evaluation
EVALUATION
  • H&P:
  • EKG: verify AF
  • CXR: lungs, vasculature and cardiac outline
  • ECHO
    • TTE: size and function of chambers, valvular heart diseases
    • TEE: thrombi in left atrium
  • TSH
  • ADDITIONAL TESTING:
    • EXERCISE TEST
    • HOLTER/EVENT MONITOR
slide9

RATE VS. RHYTHM CONTROL

  • AFFIRM AND RACE TRIALS: 2 CONCLUSIONS-
    • Embolic event occur in equal frequency
    • lower incidence of primary end point with rate control strategy
treatment
TREATMENT
  • RATE CONTROL
    • Beta blockers
    • Calcium channel blockers
    • Digoxin
    • GOALS: HR<80 bpm, 24 hr. Holter average <100 bpm, HR < 110 bpm in 6 min. walk
    • Non pharmacologic method: radiofrequency ablation and pacemaker implantation
slide11

RHYTHM CONTROL

  • PHARMACOLOGIC
  • DIRECT CURRENT CARDIOVERSION
    • Anticoagulation for 3-4 weeks before CV
    • Anticoag for 1 month after CV
    • usu done in hemodynamically unstable pts.
    • success rate is 75-93%, inversely related to atrial size and duration
contd rhythm control
…contd. RHYTHM CONTROL
  • Maintenance of NSR:
    • 20-30% maintain NSR > 1 yr. w/o antiarrythmics
      • duration of <1 yr, atrial size < 4 cm.
      • reversible causes
    • Amiodaroneis known to be most effective
      • CTAF and AFFIRM trials
  • Flecainide and propefenone in those without heart disease
anticoagulation in af
ANTICOAGULATION IN AF
  • RISK OF STROKE IS 3-5% WITHOUT ANTICOAGULATION
  • CHADS2 SCORE
    • SCORE OF 0: ASA
    • SCORE 1-2: ASA/WARFARIN
    • SCORE > 2: WARFARIN, INR GOAL 2-3
dabigatran
DABIGATRAN
  • APPROVED IN 10/10
  • RE-LY TRIAL EVALUATED SAFETY OF 2 DOSES
  • RESULTS:
  • Rate of stroke was lesser
  • High dose - more effective than warfarin
  • Risk of bleeding was lesser in low dose
  • All-cause mortality was reduced
slide16

DISADVANTAGES

  • Twice dosing
  • High cost
  • Lack of an antidote
  • Dose adjustment for those with CKD
  • lack of long term safety data