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Atrial Fibrillation Andreas Stein Robert Smith, M.D. August 11, 2003 Definition Atrial fibrillation/flutter is a disorder of heart rhythm (arrhythmia) usually with rapid heart rate, in which the upper heart chambers (atria) are stimulated to contract in a very disorganized and abnormal manner. Prevalence • Overall prevalence 1% • Increases with age • Higher in men than in women Classification • Paroxysmal AF: less than 7 days • Persistent AF: longer than 7 days • Permanent AF: longer than 1 year • Lone AF: no structural heart disease Etiology • AF with Heart disease complicated by the following is most common (~80%): – Atrial enlargement – Elevation of atrial pressure – Infiltration or inflammation of atria • Lone AF (~20%): – Electrophysiologic properties Etiology (cont) Common diseases underlying AF: • Hypertension • Coronary Heart disease / MI • • • • • • Rheumatic heart disease Dilated cardiomyopathy Hypertrophic cardiomyopathy Congenital heart disease Hyperthyroidism Inflammation Evaluation of AF History and Physical Examination: – Define symptoms associated with AF – Clinical type or “pattern” (Classification) – Onset or date of discovery – Frequency and Duration – Precipitating causes and modes of termination – Response to drug therapy – Presence of heart disease or potentially reversible causes Evaluation of AF (cont) • Electrocardiogram: – Presence of AF – Left ventricular hypertrophy – Preexcitation – Bundle branch block – Prior MI – Measure important intervals such as: RR, QRS and QT Evaluation of AF (cont) • Echocardiogram – Transthoracic Echocardiogram: • size and function of atria and ventricles • low sensitivity for thrombi – Transesophageal Echocardiogram: • High sensitivity for atrial thrombi • Need of anticoagulation prior to cardioversion • Assessment for Hyperthyroidism – TSH measurement General Treatment Issues • Rhythm control: – reversion to normal sinus rhythm • Rate control: – administration of medications to control the ventricular rate in chronic AF • Choosing between rhythm and rate control • Prevention of systemic embolization Rhythm Control • Synchronized External DC Cardioversion – hemodynamically stable and unstable patients – ~80% overall success rate • Pharmacologic Cardioversion – hemodynamically stable patients – Class IA ; IC ; III anti arrhythmic drugs – ~60% overall success rate Rule out atrial thrombi by TEE or anticoagulation for 3 – 4 week Drugs for AF <7 Days Drugs for AF >7 Days Maintenance of NSR • ~20% maintain in NSR without chronic antiarrhythmic therapy • Class IA, IC, and III drugs: – Flecainide minimal heart disease – Amiodarone reduced EF – Sotalol coronary heart disease • Alternative methods: – ablative procedures – pacing – insertion of an implantable atrial defibrillator Maintenance of NSR Rate control in chronic AF Slowing AV nodal conduction: • beta blocker • calcium channel blocker • digoxin Rhythm Control vs. Rate Control • Embolic events occur with equal frequency in rate control and rhythm control strategies • Almost significant trend toward a lower incidence of the primary end point with rate control Prevention of Systemic Embolization • Anticoagulation during restoration of NSR – AF > 48 hours 3 to 4 weeks of warfarin prior to and after cardioversion – recommended target INR is 2.5 • Anticoagulation in chronic AF – Aspirin: low risk patients (<65y; no risk factors) – Warfarin: other than low risk patients ~70% reduction of stroke