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Atrial Fibrillation

Atrial Fibrillation. Current Management Strategies. Overview. 25% will develop AF during lifetime 4% above 60 8% above 80 Total sufferers to double by 2050 Doubles annual risk of death (Framingham) 5% annual risk of stroke. Definitions. Paroxysmal AF Under 7 days 2 or more episodes

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Atrial Fibrillation

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  1. Atrial Fibrillation Current Management Strategies

  2. Overview • 25% will develop AF during lifetime • 4% above 60 • 8% above 80 • Total sufferers to double by 2050 • Doubles annual risk of death (Framingham) • 5% annual risk of stroke

  3. Definitions • Paroxysmal AF • Under 7 days • 2 or more episodes • Persistent AF • 7 days to 1 year • Permanent AF • Over 1 year with/without intervention • Accepted for rate control

  4. Pathophysiology Supraventricular ectopic focus with permissive atrial substrate Younger Myocytes in pulmonary veins Drugs and alcohol Metabolic abnormalities Electrolyte abnormalities Sepsis Older LVH/aortic stenosis Atrial ischaemia and IHD Mitral stenosis/incompetence Hypertension Catecholamine drive Sepsis

  5. Two Considerations • Reduce ventricular rate • Cardiovert • Slow • Prevent thromboembolism • Cardiovert • Anticoagulate

  6. Treatment Strategies Paroxysmal Persistent Permanent Symptoms Persist Rhythm Control Rate Control Failure Rhythm Control Younger First presentation Underlying cause treated Symptomatic Heart Failure Rate Control Older Coronary artery disease Contraindications to cardioversion Previous failure

  7. Rhythm Control – Paroxysmal AF • All need assessment for anticoagulation • May need cardioversion (but aim to avoid) • Pill in pocket may be appropriate (flecanide) • Standard beta-blocker first line (bisoprolol) • If failure: • CAD – Sotalol • LVD – Amiodarone

  8. Rhythm control – Persistent AF Onset < 48 hours Emergency Department Outpatient Management Heparinise Warfarinise Electrical Chemical Failure likely? Flecanide Amiodarone Rate Control Sotalol or Amiodarone

  9. Rate control – Persistent or Permanent • All patients need assessment for anticoagulation • Aim for rate under 100 (may need nothing) • Beta-blocker of calcium channel antagonist • Add digoxin if further control necessary

  10. Thromboembolism • Ineffective atrial contraction • Venous pooling in atrial appendage • Embolism

  11. CHAD2Vasc • Congestive Cardiac Failure • Hypertension • Age > 75 (2) > 65 (1) • Stroke/TIA/DVT/PE (2) • Vascular disease • Diabetes • Female 0 – Low risk 1 – Moderate risk > 2 high risk

  12. European Society of Cardiology High Risk CVA TIA VTE Medium Risk > 75 HTN EF < 35% DM No Risk Warfarin Aspirin

  13. Ablation/MAZE procedure • 1:1000 death • 1:50 complications • 60% success

  14. Case 1 • 40, fit and healthy, normal ET, normal resting ECG • Onset AF@135bpm 24 hours ago, first event • Haemodynamically stable • Bloods normal Anticoagulant? Heparin then Aspirin 75mg Cardioversion? Flecanide 300mg Maintenance? Pill in pocket

  15. Case 2 • 60, on carbimazole and bendroflumethiazide • AF for 24 hours, otherwise normal examination • All bloods normal including TFTs Anticoagulant? Heparin then warfarin Cardioversion? Electrical (not amiodarone) Maintenance? Bisoprolol

  16. Case 3 • 28 fit and well, onset AF 3 hours ago • Mild symptoms, examination normal • Bloods normal Anticoagulant? Heparin then aspirin Cardioversion? Not today, return starved tomorrow Maintenance? Pill in pocket

  17. Case 4 • 89, SOB, tachycardic, febrile, cough • Raised WCC and ARF and hypokalaemia Anticoagulant? Probably Cardioversion? Not until treated Maintenance? Review prior to discharge

  18. Case 5 • 80, hypertensive, smoker with COPD • Incidental finding, symptom free • Rate 110bpm Anticoagulant? Warfarin Cardioversion? No Maintenance? Diltiazem

  19. Case 6 • 50, AF 8 hours, ejection systolic murmur • Bloods normal Anticoagulant? Heparin then aspirin Cardioversion? Amiodarone Maintenance? Bisoprolol

  20. Case 7 • 50, AF 8 hours, ejection systolic murmur • Bloods normal Anticoagulant? Heparin then aspirin Cardioversion? Amiodarone Maintenance? Bisoprolol

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