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Atrial Fibrillation

Atrial Fibrillation. Rate or rhythm control? Who should be anticoagulated? Other treatment strategies. Classification:. Aetiology. LONE AF. VS. ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC. Classification:. Aetiology. Timing. LONE AF. FIRST EPISODE. VS. OR.

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Atrial Fibrillation

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  1. Atrial Fibrillation • Rate or rhythm control? • Who should be anticoagulated? • Other treatment strategies

  2. Classification: Aetiology LONE AF VS ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC

  3. Classification: Aetiology Timing LONE AF FIRST EPISODE VS OR ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC RECURRENT PAROXYSMAL PERSISTENT PERMANENT Circulation 2001;104:2118 –2150

  4. Prevalence of AF: JAMA. 2001;285:2370-2375

  5. Mechanism of AF:

  6. Mechanism of AF:

  7. Mechanism of AF:

  8. Burden of AF: Palpitations AF 5% > 65 Syncope/Presyncope Fatigue

  9. Burden of AF: Palpitations AF 5% > 65 Syncope/Presyncope Fatigue DyspnoeaOedema Stroke Heart Failure

  10. Prognosis of AF: Circulation1998;98:946-952

  11. Principles of management: • RESTORATION & MAINTENACE OF SINUS RHYTHM‘Rhythm control’ • CONTROL OF VENTRICULAR RATE‘Rate control’ • REDUCE THROMBOEMBOLIC RISK

  12. Restoration of SR: RESTORATION OF SINUS RHYTHM NB 60% REVERT SPONTANEOUSLY IN <24 HOURS ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK • PHARMACOLOGICAL • 1) FLECAINIDE: • 2) PROPAFENONE • 3) AMIODARONE • 4) DOFETILIDE

  13. Restoration of SR: ANTICOAGULATION? RESTORATION OF SINUS RHYTHM HOW LONG IN AF? NB 60% REVERT SPONTANEOUSLY IN <24 HOURS ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK • PHARMACOLOGICAL • 1) FLECAINIDE: • 2) PROPAFENONE • 3) AMIODARONE • 4) DOFETILIDE <48 HOURS NO HEPARIN 3 WEEKS WARFARIN POST SHOCK >48 HOURS 3 WEEKS WARFARIN PRE & POST SHOCK or TOE GUIDED SHOCK + 3 WEEKS WARFARIN POST SHOCK

  14. Maintenance of SR (=prevention of AF recurrences): 1) DRUG TREATMENT:

  15. Maintenance of SR (=prevention of AF recurrences): • 2) OTHER TREATMENTS: • Pacing • Atrial Defibrillators • Cardiac Surgery • Catheter radiofrequency ablation

  16. Rate control: VENTRICULAR RATE CONTROL PHARMACOLOGICAL 1) DIGOXIN 2)  BLOCKER 3) CA CHANNEL BLOCKER 4) AMIODARONE • ABLATION • RADIOFREQUENCY • ABLATION OF • ATRIOVENTRICULAR NODE • + • PACEMAKER

  17. Rate vs rhythm control: Rate (Remain in AF):Rhythm (Restore SR): advantages Good symptom control Good symptom control Simple low risk treatment Normal physiology/cardiac function Better prognosis ?? disadvantages Abnormal cardiac function Complex higher risk treatment Stroke risk ?? Antiarrhythmic drugs - proarrhythmic Worse prognosis??

  18. Rate vs rhythm control - PIAF: PIAF study Lancet 2000;356;1789-94

  19. Rate vs rhythm control – AFFIRM: n = 4000  age = 70 • Rate: • Digoxin •  Blocker • Ca channel blocker • Rhythm: • Amiodarone • Propafenone • Sotalol • +/- DC Cardioversion AFFIRM study - NASPE 2002

  20. Risk of Stroke? • 1 in 6 strokes have AF • 6 x stroke rate if have AF • TYPE OF AF IS NOT A RISK DETERMINANT Optimal INR?

  21. Who should be anticoagulated?

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