Download Update in Atrial Fibrillation

Update in Atrial Fibrillation
พญ.กนกศรี อั ศ วสั น ติ
อายุ ร แพทย์ โรคหั ว ใจและหลอดเลื อ ด
กลุ่ มงานอายุ ร กรรม โรงพยาบาลเพชรบู ร ณ์
 1-2% of general population
 Average age 75 – 85 years
 5 fold risk of stroke
 3 fold risk of CHF
 Higher mortality
Causes of AF
Cardiovascular
 VHD
Non cardiovascular
 Aging
- rheumatic MS
 DM
- prosthetic heart valve
 Obesity, sleep apnea
- MV repair
 Hyperthyroid / Hypothyroid
 Myocardial disease
 COPD
 Coronary artery disease ( CAD )
 Sepsis
 Congenital heart disease ( e.g. ASD )
 CKD
 HT
 Post surgery
Mechanisms of AF
Extracardiac
Factors:
Hypertension
Obesity
Sleep apnea
Hyperthyroidism
Alcohol/drugs
Atrial Structural
Abnormalities:
Fibrosis
Dilation
Ischemia
Infiltration
Hypertrophy
Inflammation
Oxidative stress
AF
Atrial tachycardia
remodeling
Genetic Variants:
Channelopathy
Cardiomyopathy
RAAS activation
Atrial Electrical
Abnormalities:
↑Heterogeneity
↓Conduction
↓Action potential duration/refractoriness
↑Automaticity
Abnormal intracellular Ca++ handling
Autonomic
nervous system
activation
Clinical presentations of AF
 Asymptomatic
 Dyspnea on exertion, exercise intolerant
 Palpitation
 Syncope
 Heart failure
 Systemic thromboembolism ( stroke, acute arterial occlusion )
Physical examination
 irregulary irregular pulse rate
 signs of associated diseases
Screening for AF
Pulse palpation in patient age > 65
If irregular  ECG
Investigations in AF
 Blood chemistry ( e.g. CBC, serum Cr )
 TFT
 CXR
 Echocardiogram
 Holter monitoring
Definitions of AF: A Simplified Scheme
Term
Definition
Paroxysmal AF


AF that terminates spontaneously or with intervention within 7 d of onset.
Episodes may recur with variable frequency.
Persistent AF

Continuous AF that is sustained >7 d.
Long-standing
persistent AF

Continuous AF >12 mo in duration.
Permanent AF

The term “permanent AF” is used when the patient and clinician make a joint decision to stop
further attempts to restore and/or maintain sinus rhythm.
Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician
rather than an inherent pathophysiological attribute of AF.
Acceptance of AF may change as symptoms, efficacy of therapeutic interventions, and patient
and clinician preferences evolve.


Nonvalvular AF

AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or
mitral valve repair.
Valvular AF
Nonvalvular AF
1. Rheumatic mitral stenosis
2. Prosthetic heart valve
3. Mitral valve repair
Lone AF
1. Nonvalvular AF
2. Age < 65 year
Management of AF
 Rhythm control : restoration and maintenance of sinus rhythm
 Rate control : ventricular rate
 Clot control : prevention of thromboembolic event
Rhythm control ( recent-onset AF < 48 hrs )
 Medical cardioversion
 Electrical cardioversion
 Pill in pocket : paroxysmal AF
Strategies for Rhythm Control in Patients with
Paroxysmal* and persistent AF†
Direct current cardioversion
 Informed- consent : indication and complication
 Adequate sedation
 AP electrode placement more effective than anterolateral placement
 Biphasic waveform : 150-200 J
 If PPM or ICD : electrode paddle at least 8 cm from generator
Factor predispose to AF recurrence
 Age
 AF duration before cardioversion
 Number of previous recurrence
 Increase LA size
 Reduced LV function
 Presence of CAD or pulmonary or mitral valve disease
 Atrial ectopic beat with long – short sequence
 Faster HR
 Variation in atrial contraction
Rhythm control
AF > 48 hrs
Rate control
 Stable : BB / non dihydrpyridine CCB
 Severely compromised : iv Verapamil/ Metoprolol / Digoxin
 Severe Depressed LV function : Amiodarone
 AF with slow ventricular response : Atropine
if symptomatic bradycardia  TPM
**** After acute control  follow with long term rate control
Approach to Selecting Drug Therapy for Ventricular
Rate Control*
Atrial Fibrillation
No Other
CV Disease
Beta blocker
Diltiazem
Verapamil
Hypertension
or HFpEF
LV
Dysfunction
or HF
COPD
Beta blocker
Diltiazem
Verapamil
Beta blocker†
Digoxin‡
Beta blocker
Diltiazem
Verapamil
Amiodarone§
Asymptomatic
Preserved LVEF
< 110 bpm
Symptom evaluation : EHRA score
Clot control : Anticoagulant
prevention of systemic thromboembolism
Valvular AF  VKA for all
Antithrombotic Therapy to Prevent Stroke in Patients who Have Nonvalvular AF
(Meta-Analysis)
Adjusted-dose warfarin
compared with placebo
or control
Antiplatelet agents
compared with placebo
or control
Adjusted-dose warfarin
compared with
antiplatelet agents
Adapted with permission from Hart et al.
Recommendations
COR
LOE
I
A
• dabigatran, or
I
B
• rivaroxaban, or
I
B
• apixaban.
I
B
For patients with nonvalvular AF with prior stroke,
transient ischemic attack, or a CHA2DS2-VASc score of
2 or greater, oral anticoagulants are recommended.
Options include:
• warfarin (INR 2.0 TO 3.0), or
Recommendations
COR
LOE
For patients with nonvalvular AF and a CHA2DS2-VASc score
of 0, it is reasonable to omit antithrombotic therapy.
IIa
B
For patients with nonvalvular AF and a CHA2DS2-VASc score
of 1, no antithrombotic therapy or treatment with an oral
anticoagulant or aspirin may be considered.
IIb
C
Risk of bleeding : HASBLED
 Hypertension : SBP> 160 mmHg
 Abnormal renal and liver function
- Chronic dialysis, renal transplant, serum creatinine ≥ 200 mmol/L ( 2.26 mg/dL )
- Chronic hepatic disease ( cirrhosis ) , bil > 2 x UNL , AST, ALT > 3 x UNL
 Stroke
 Bleeding
- Previous bleeding Hx and /or predisposition to bleeding – bleeding diathesis, anemia
 Labile INRs
- Unstable / High INR or poor time in therapeutic range < 60%
 Elderly : >65 yr
 Drug or alcohol
- Use antiplatelet, NSAID, alcohol abuse
High risk
Point ≥ 3
Optimal INR
 INR 2.0 – 3.0 for prevent systemic emboli in Nonvalvular AF
 INR 1.8 – 2.5 in elderly ( not based on any large trial evidence )
 CYP2C9 and VKORC1 genotypes
– influence warfarin dose requirement and asso with bleeding event
Specific patient groups and AF
 ACS
- DC if unstable situation ( hypotension or shock, HF, persistent angina)
- VKA with CHA2DS2-VASc score
 Hypertrophic cardiomyopathy
- VKA independent of CHA2DS2-VASc score
 Hyperthyroidism
- VKA with CHA2DS2-VASc score
- BB for rate control
Specific patient groups and AF
 COPD
- VKA with CHA2DS2-VASc score
- Nondihydropyridine CCB for rate control
 HFpEF
- BB or Nondihydropyridine CCB for rate control
- caution needed in patients with overt congestion, hypotension, or HFrEF
 HFrEF
-Digoxin or Amiodarone for rate control
 Postoperative AF
AF with WPW and Pre-excitation syndrome
WPW ( Wolf-Parkinson-White syndrome)
 Short PR interval <120 msecs.
 QRS > 100 msecs.
 Delta wave = slurred upstroke at beginning of QRS.
Type A
Positive QRS
in V1
Type B
Negative QRS
in V1
Recommendations
Prompt direct-current cardioversion is recommended for
patients with AF, WPW syndrome, and rapid ventricular
response who are hemodynamically compromised.
Administration of intravenous amiodarone, adenosine,
digoxin (oral or intravenous), or nondihydropyridine calcium
channel antagonists (oral or intravenous) in patients with
WPW syndrome who have pre-excited AF is potentially
harmful because these drugs accelerate the ventricular rate.
COR LOE
I
C
III:
Harm
B