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AF: Points of Focus

Atrial Fibrillation What is New in the 2006 ACC/AHA/ESC Guidelines HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation. May 2007. AF: Points of Focus. Classification, epidemiology, and mechanisms Consequences of AF and aims of therapy Anticoagulation Rate control

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AF: Points of Focus

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  1. Atrial FibrillationWhat is New in the 2006 ACC/AHA/ESC GuidelinesHRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation. May 2007

  2. AF: Points of Focus • Classification, epidemiology, and mechanisms • Consequences of AF and aims of therapy • Anticoagulation • Rate control • Rhythm control • Rate vs. rhythm control: What to do? • Catheter ablation for AF: What is the current status

  3. AF:Classification • First detected episode • Recurrent AF (after 2 or more episodes) • Paroxysmal (spontaneous termination) • Persistent (lasting beyond 7 days, or termination with drugs or DCCV) • Permanent AF: Sinus rhythm can not be restored • Lone AF: Pts. younger than 60. No clinical or echo evidence for cardiac disease • Nonvalvular AF: Cases without RMV disease, prosthetic heart valve, or valve repair.

  4. AF Definition • Paroxysmal AF: Recurrent AF (2 episodes) that terminates spontaneously within 7 days. • Persistent AF: AF which is sustained beyond seven days, or lasting less than seven days but necessitating pharmacologic or electrical cardioversion. • Longstanding persistent AF: is defined as continuous AF of greater than one-year duration. • Permanent AF: Sinus rhythm could not be restored and a decision has been made not to pursue restoration of sinus rhythm by any means, including catheter or surgical ablation.

  5. AF: Prevalence and Incidence • Prevalence: • 0.4% - 1% in the general population • 8% in population over 80 years old • Lone AF: Less than 12% of all AF cases • Incidence: • 0.1% per year in people < 40 years old • 2.0% per year in men > 80 years old • 10% is the 3-y incidence in HF patients

  6. AF: Prevalence and StrokesThe Framingham Study 30 AF prevalence Strokes attributable to AF 20 % 10 0 50–59 60–69 70–79 80–89 Age Range (years) Wolf et al. Stroke 1991;22:983-988.

  7. Cardiac causes Hypertension Coronary artery disease Congestive heart failure Pericarditis/Myocarditis Valvular heart disease Non-cardiac causes Electrolyte disturbances Thyroid dysfunction Ethanol intoxication Vagal/sympathetic imbalance Pulmonary disease Sepsis, febrile illness AF: Common Clinical Causes Appropriate work-up should be done and reversible causes identified and treated

  8. AF: Mechanisms • Rapidly firing atrial foci (hyperexcitability) • Macroreentry with fibrillatory conduction (mother wave) • Multicircuit reentry Multicircuit reentry(Mines, Garrey) Mother wave(Lewis) Hyperexcitability(Engelmann, Winterberg) Remodeling acts to make multicircuit reentry a common final pathway Nattel et al. Ann Rev Physiol 2000;62:51-77.

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