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Atrial Fibrillation “Pearls and Pitfalls”

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”

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  1. Atrial Fibrillation“Pearls and Pitfalls” Sean P. Mazer, MD October 17, 2009

  2. Conflicts of Interest Consultant for St. Jude Medical Consultant for Medtronic

  3. 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.

  4. 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

  5. van der Hooft,CS et al. Arch Int Med 2006:1016-1020

  6. 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.

  7. 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?

  8. Pappone et al. JACC 2006

  9. 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

  10. 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.

  11. 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

  12. 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

  13. 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

  14. 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.

  15. 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

  16. 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.

  17. Atrial Fibrillation Up to 40% of strokes are caused by Atrial Fibrillation

  18. 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

  19. 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

  20. 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.

  21. 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.

  22. 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

  23. 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)

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

  25. 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.

  26. 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:

  27. 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?

  28. Family History • What did they die from? • How old were they? • Drowning? • Accidents? • Heart Attacks? • Pacemakers?

  29. 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)

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

  31. 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

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