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ATRIAL FIBRILATION

Learn the first steps to confirm and treat atrial fibrillation (AF). Understand diagnosis, treatment options, and follow-up protocols.

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ATRIAL FIBRILATION

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  1. ATRIAL FIBRILATION Raj Chahal

  2. First Steps • CONFIRM DIAGNOSIS (ECG) • IMMEDIATE RESUSCITAION • AIRWAY • BREATHING • CIRCULATION • HAEMODYNAMIC PROFILE • HEART RATE • BLOOD PRESSURE

  3. TYPES • PERMANENT • PERSISTENT • PAROXYSMAL

  4. AF WITH FAST VENTRICULAR RATE • AF WITH APPROPRIATE RATE

  5. UNSTABLE • HYPOTENSIVE • CHEST PAINS • Consider reversible causes • Haemorrhage • PE • Call senior help and consider emergency DCCV under sedation.

  6. STABLE • History and Examination • Confirm diagnosis • Consider exacerbating causes • Stroke risk assessment • Rate or Rhythm control

  7. Exacerbating Causes • Infection • Hyperthyroidism • Alcohol • Caffeine • Surgery • Ischaemia

  8. Stroke Risk Assessment • CHADS2 SCORE • Cardiac Failure • Hypertension • Age over 75 • Diabetes • Stroke/TIA (2) 0 - Aspirin alone 1 - Aspirin or Warfarin ≥2 - Warfarin Consider patient choice and logistics/safety of warfarin

  9. Rate or Rhythm Control

  10. Try rhythm-control first for patientswith persistent AF: • who are symptomatic • who are younger • presenting for the first time with lone AF • secondary to a treated or corrected precipitant • with congestive heart failure. • CARDIOVERSION FROM AF • MAINTENANCE OF SR

  11. Try rate-control first for patients with persistent AF: • over 65 • with coronary artery disease • with contraindications to antiarrhythmic drugs • unsuitable for cardioversion

  12. Practicalities • On initial assessment on finding AF before deciding on aspirin or warfarin • GIVE THERAPEUTIC DOSE LMWH DALTPARIN (FRAGMIN) unless contraindicated

  13. Rhythm Control - cardioversion • Consider onset • <48 hours • >48 hours • If less than 48 hours then less chance of thrombus formation. • IV amiodorone 300mg over 1 hour • IV amiodorone 900-1200mg over 23 hours • DCCV under sedation

  14. If greater than 48 hours • Warfarin for 3-6 weeks • Request echo • Request DCCV • Continue warfarin for 4 weeks post • In high risk of recurrence, continue warfarin

  15. RHYTHM CONTROL – maintenance • When back in SR consider medication to maintain in SR. • Oral amiodarone (remember counselling & monitoring) • 200mg tds 1/52; 200mg bd 1/52; 200mg od thereafter • If no structural heart disease: • Oral flecainide • Oral sotalol • Oral propafenone

  16. RATE CONTROL • In permanent AF • Left atrial enlargement • AF over year • Recurrent AF • Use beta-blocker (bisoprolol) or rate limiting calcium channel blocker (diltiazem) • Further rate control can be gained with digoxin and amiodarone

  17. FOLLOW UP • In those with rhythm control check with 24 hour ECG as OP after 4/52

  18. Questions?

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