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The Internists Approach to Atrial Fibrillation:

The Internists Approach to Atrial Fibrillation:. A Simple Strategy for a Complex Problem Peter Holzberger, MD 12/4/03. Focus . Immediate Treatment Anticoagulation Maintenance Issues. Background. Atrial fibrillation is the most common sustained arrhythmia Affects 2 million Americans

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The Internists Approach to Atrial Fibrillation:

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  1. The Internists Approach to Atrial Fibrillation: A Simple Strategy for a Complex Problem Peter Holzberger, MD 12/4/03

  2. Focus • Immediate Treatment • Anticoagulation • Maintenance Issues

  3. Background • Atrial fibrillation is the most common sustained arrhythmia • Affects 2 million Americans • 6% over the age of 65 experience it • Responsible for 15% strokes • Benjamin E: Epidemiology of Atrial Fibrillation. In Falk RH, Podrida PJ, eds:Atrial Fibrillation: Mechanisms and Management. 2nd Ed, Lippincott-Raven Press, New York 1997, pp.1-22.

  4. Atrial Fibrillation Demographics by Age U.S. populationx 1000 Population with AFx 1000 Population withatrial fibrillation 30,000 20,000 10,000 0 500 400 300 200 100 0 U.S. population <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 >95 Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473. Age, yr

  5. Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis. • 6% PSVT • 6% PVCs • 18% Unspecified 2%VF • 4% Atrial Flutter • 9% SSS • 34% Atrial Fibrillation • 8% Conduction Disease • 10% VT • 3% SCD Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

  6. Symptoms • Inappropriate heart rate response • Tachymyopathy • Irregular rate • Loss of atrial systolic function • Thromboembolism

  7. Guidelines

  8. Immediate Treatment • Cardiovert • Hemodynamic collapse • Control the Rate Assess symptoms

  9. Immediate Treatment • Significant symptoms • Restore NSR +/- Antiarrhthymics • Minimal symptoms • Strongly Consider rate control

  10. Immediate Treatment • History,Physical,Labs • Underlying heart disease,thyroid,alcohol • ECG • LVH, WPW, MI • CX • Pneumonia • Echocardiogram • Blown ticker • ETT/Holter • Rate assessment

  11. Immediate Treatment • Categorize the atrial fibrillation • Follow the flowchart • When faced with the antiarrhythmic option consider getting a referral • almost never needed in the acute decision process • exception: IV Amiodarone

  12. Guidelines: Definitions

  13. Case: 1 • 40 yr old male • Seen in ED with new onset palpitations • Started 2 hrs ago • Otherwise healthy but nervous • ECG: atrial fib 160 • Rx’d with beta blocker: HR 85 • Feels much better

  14. Categorize • 1: Is it Paroxysmal? • 2: Is it Persistent? • 3: Is it Permanent?

  15. What Next? • 1: DC Cardioversion +/- TEE • 2: IV Amiodarone • 3: IV Ibutilide • 4: Come back in 24 hrs and reevaluate

  16. Placebo • Cotter et al,.Eur Heart J Dec 1999; 20(24):1833-42 P=0.0017 Conversion (%)

  17. < 24 hrs duration • Minimally symptomatic with rate control • Observe for another 24 hrs (may be paroxysmal) • Anticoagulate if indicated

  18. < 48hrs but > 24hrs • Cardiovert if NSR is desirable • Most patients with new onset atrial fibrillation regardless of age • Rate control and anticoagulation if appropriate • Hx or recurrent paroxysmal with minimal sx’s usually in the elderly

  19. Case: 2 • 50 yr old female hasn’t felt well for 3 days • Otherwise healthy • ECG atrial fib rate 140 • Rx’d beta blocker: HR 105 • Still feels terrible

  20. What next? • 1: DC Cardioversion +/- TEE • 2: IV Amiodarone • 3: IV Ibutilide • 4: Come back in 24 hrs and reevaluate

  21. Manning WJ. N Engl J Med. 1993;328:750-755. A Left Atrium B Left Atrial Appendage Clot

  22. > 48 hrs • TEE cardioversion followed by anticoagulation if symptom intolerant • Rate control and anticoagulation for 1 month before attempted cardioversion if NSR is desired • Long term rate control and anticoagulation

  23. Guidelines:Newly Discovered AF

  24. Guidelines:Recurrent Paroxysmal

  25. Case: 3 • 83 yr old noted to be in atrial fibrillation on routine office visit - asymptomatic • Otherwise healthy except for HTN • Wonders what all the fuss is about • Evaluation for underlying causes is negative

  26. What next? • 1: If it ain’t broke don’t fix it • 2: Anticoagulate, rate control and cardiovert 1 month later • 3: Anticoagulate and rate control • 4: Rate control

  27. Case: 4 • 38 yr old with atrial fib noted on routine physical asymptomatic • Otherwise healthy • Evaluation unremarkable

  28. What next? • 1: If it ain’t broke don’t fix it • 2: Anticoagulate, rate control and cardiovert 1 month later • 3: Anticoagulate and rate control • 4: Rate control

  29. Guidelines: Recurrent Persistent

  30. Rate Control : A New Paradigm • 5 Randomized trails of Rhythm vs. Rate • PIAF - 252 • PAF2 - 141 • RACE - 522 • STAF - 200 • AFFIRM - 4060 patients • 3.5 yrs

  31. AFFIRM

  32. Stroke • AFFIRM • 77 (5.5%) rate control and 80 (7.1%) rhythm control • 1% per year • Majority associated with no Coumadin or INR <2 • RACE • 14 (5.5%) rate control and 21 (7.9%) rhythm control • 6 strokes after stopping Coumadin (5 in sinus) • 23 with INR <2

  33. Anticoagulation: The Gold Standard • 5 large prospective randomized trials • All comparing warfarin to placebo while utilizing rate control. • All with the same highly significant result • Embolic risk decreases to 1.4% (68% reduction)

  34. Warfarin

  35. Who Gets Warfarin?

  36. Everyone with Atrial Fibrillation Except: “Lone” Atrial Fibrillation Absence of identifiable cardiovascular, pulmonary, or associated systemic disease Approximately 0.8 - 2.0% of patients with atrial fibrillation (Framingham Study)1 In one series of patients undergoing electrical cardioversion, 10% had lone AF.2 1 1Brand FN. JAMA. 1985;254(24):3449-3453.2 Van Gelder IC. Am J Cardiol. 1991;68:41-46.

  37. Predictors of Thromboembolic Risk in Atrial Fibrillation • Previous Stroke or TIA - 2.5 • History of HTN - 1.6 • CHF - 1.4 • Advanced Age >65 yrs (cont. per decade) - 1.4 • DM - 1.7 • CAD - 1.5 Atrial Fibrillation Investigators. Arch Intern Med. 1994;154:1449-1457.

  38. Exception for 325 mg ASA Age <75 yrs No risk factors Normal echo

  39. How to treat the symptomatic • Referral: • Antiarrhthymics • Ablation • AV Junction • Pulmonary Veins • Surgery • MAZE

  40. Maintenance Issues • Rate Control • Annual Holter with mean HR below 100 • Anticoagulation • Monthly INR when stabilized • Antiarrhythmic Rx • Periodic ECG, drug level -if possible, LFT and kidney function

  41. Atrial Fibrillation: Surgery • Hold anticoagulation 4 days prior to surgery • Start back on day of surgery • Exceptions • High risk embolization-bridge with heparin • Embolization within 3 months • Mechanical mitral valve

  42. Case: 5 • 70 yr old male with HTN develops atrial fib post op day 2 following emergency cholycystectomy • Rate is adequately controlled • No acute issues • No prior history of atrial fib

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