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दुःु खेषु अनद् ु विग्न मनुः सुखेषु विगत स्प्रह ृ ुः िीत राग भय क्रोधुः स्स्प्ितधीर् मुननरुच्यते ॥ dukhaeshu anudwigna manah, sukhaeshu vigatha sprihah | veeta raaga bhaya krodhah, sthitha dheer munir uchyatae || Never down in the dumps when confronted with sorrow Not elated and on cloud nine when gifted with happiness Devoid of passion, attachment, fear and anger - always He is the one qualified as the wise by the most eminent Dr Alan E Lindsay • • • • • • • • • • ACC/AHA/ESC guidelines on AF - Eur Heart J (2001) 22 http://emedicine.medscape.com/article/151066 http://emedicine.medscape.com/article/1530542 http://www.nhlbi.nih.gov/health/dci/Diseases/af/af_what http://www.afibprofessional.org/ Hurst’s The Heart – Manual of Cardiology Essential Cardiology – Clive Rosendorff Practical Cardiology – R R Baliga, Kim A Eagle In A Page Cardiology – Scott Kahan, Rajnish Prasad Cardiology Explained – Euan A Ashley, Josef Niebauer Atrial fibrillation and atrial flutter are very fast electrical discharge patterns that make the atria contract very rapidly, with some of the electrical impulses reaching the ventricles and causing them to contract faster and less efficiently than normal • • • • • • • It is a supraventricular tachyarrhythmia The most common arrhythmia seen in clinical practice Almost 5% of the population older than 70+ years The prevalence of AF increases dramatically with age AF is associated with a 1.5- to 1.9-fold risk of death It’s characterized by disorganized atrial electrical activity Progressive deterioration of atrial electromechanical function with several theories of abnormal activity • • • • • • • Absence of P waves – see leads LII, LIII, aVF and V1 Rapid oscillations (or fibrillary [f] waves) Low amplitude wavelets or mostly flat base line These vary in amplitude, frequency, and shape AF has a typically irregular ventricular response Irregularly irregular heart and pulse Narrow QRS usually, reentrant pathway wide QRS The short PR interval is due to a bypass track, also known as the Kent pathway. By bypassing the AV node - the PR shortens. The delta wave represents early activation of the ventricles from the bypass tract. The fusion QRS is the result of two activation sequences, one from the bypass tract and one from the AV node. The ST-T changes are secondary to changes in the ventricular activation sequence. • • • • • • • Kent pathway Accessory pathway Shortened PR Interval Delta wave Double activation Fusion QRS complex At risk of VF and death • • • • • • • Initiating event and permissive atrial substrate Multiple mechanisms may be present Focal pulmonary vein triggers – enlarged RA or LA Multiple wavelets, mother waves, daughter wavelets Fixed or moving rotors & macro-reentrant circuits Automatic foci in atria Catecholamine excess, hemodynamic stress, atrial ischemia, atrial inflammation, metabolic stress • • • • • • • • Due to the risk of thromboembolic disease Due to its associated risk factors Loss of normal atrial contraction – Stasis of blood Development of Thrombus in the atrial appendage Dislodged clot leads to embolic complications Non RHD, Non valvular cases – stroke rate 5-7% In RHD – stoke rates are 5 fold more Mortality is doubled with underlying structural HD AF present with a wide array of symptoms • Majority are asymptomatic • Palpitations, dyspnea, fatigue, dizziness, angina • Decompensate heart failure, Polyuria ( BNP) In addition, AF can be associated with • Hemodynamic dysfunction, CHF • Tachycardia-induced cardiomyopathy • Systemic Thromboembolism • • • • • • • • • Irregularly irregular heart beat – pulse-apex disparate May or may not have tachycardia – depends on AVN Variable intensity of 1st heart sound Occasional S3; But S4 is absent in all, Absence of ‘a’ waves in Jugular Venous Pulse (JVP) Signs of underlying heart disease, RHD, CAD, HCM, DCM Look for Cardiac Failure and Atrial Embolization May have WPW associated – Ventricular rate > 200 Normally narrow QRS tachycardia, may be wide QRS <60 yrs 1% 80+ yrs 4% 60-79 yrs 8% Rheumatic Valvular Heart Disease (RVHD) Diabetes, Hypertension , CAD, LV Dysfunction Male Gender, Advancing Age, Hyperthyroidism Congenital or Structural Heart Disease, LA, RA Cardiomyopathy, Alcohol use, Illicit Drugs Acute pulmonary problems, Cardiac Surgery • Hemodynamic stress: intra-atrial pressure – Mitral and tricuspid valve disease, LV dysfunction – Systemic or pulmonary hypertension • Atrial Ischemia: CAD, Ventricular Ischemia LAP • SSS, Inflammation, Drug use, Alcohol • Endocrine (hyperthyroidism), Neurologic – SAH, Stroke • Familial Atrial Fibrillation • Cardiac Surgery, Collagen Diseases • AF with structural heart disease (RVHD, HT Heart, Cardiomyopathy, Congenital Heart Disease, CAD) • Elevated BNP suggests underlying heart disease • AF without concomitant structural heart disease • “Lone Atrial Fibrillation” – AF in younger patients without structural heart disease with lower risk of TE • Hemodynamic instability – severe dyspnea, reduced O2 saturation, fall of BP, severe chest pain, shock etc. • 12 Lead ECG with rhythm strip – Look for pre excitation, Determine Heart Rate – Evaluate for LVH, LBBB, Previous MI – QT-QRS intervals for pts on anti arrhythmic drugs • Six-minute walk test or exercise test (rate control) • Holter monitoring; Electrophysiology only in selected cases • Echocardiography (TTE), TEE (to study the atria) • Chest X-Ray to evaluate pulmonary disease • Thyroid function, Renal Function, Serum Electrolytes • • • • • • • • Atrial Flutter Atrial Tachycardia AVNRT (Atrio Ventricular Nodal Reentry Tachycardia) PSVT (Paroxysmal Supra Ventricular Tachycardia) WPW syndrome Digoxin Toxicity Cardiac Ischemia secondary to Rapid Ventricular rate Hyperthyroidism, Pulmonary Disease Diagnosis of AF Chronic Atrial Fib New Onset AF Paroxysmal Up to 7 d Persistent > 7 days Permanent CV failed • Paroxysmal AF: if it terminates spontaneously in fewer than 7 days (often in <24 h). • Persistent AF: when it terminates either spontaneously after 7 days or following cardio version. • Permanent AF: It persists for more than one year, either because cardio version has failed or because cardio version has not been attempted Paroxysmal Permanent New Onset Persistent • Is it primary or secondary – A thorough evaluation is a must • Structural heart disease and age are most important factors • AF without structural heart disease is “Lone Atrial Fibrillation” • MVD, AVD, HT, CAD, LVD, DCM, HCM, PE, ASD, Thyroid fun • Coffee, Tobacco, Ethanol, Stress, Fatigue – may trigger AF • No organic HD, No WPW – Address the precipitating factors • Observe for recurrence of AF • If HD is underlying – AC, Rate control, Rhythm control needed. • If no underlying HD – Rest, Sedation, Digitalis for the attack • Hemodynamic compromise – immediate cardioversion • Hemodynamically stable – Rate control, AC & Rhythm control • Beat Blockers, CCB, Flecainide, Propafenone – IV may be given • No structural Heart Disease - Flecainide, Propafenone preferred • Amiodarone is in patients with HF, DCM, structural HD • Sotalol in CAD and HT without LVH • Catheter ablation and MAZE procedure in refractory cases • Ventricular rate control and Anticoagulation are the best • Cardioversion needed only if hemodynamic benefit is seen • Either pharmacological or DC cardioversion can be tried • Usually no more than one attempt of DC cardioversion • Reverting to sinus rhythm didn’t give extra benefit (AFFIRM) • Long term anticoagulation is a must – risk benefit titration • Catheter ablation to HIS bundle with pace maker implant • Only if refractory as it makes the pt pace maker dependent Relief of Symptoms & Prevent recurrence, HF Prevention of Systemic Thromboembolism Tachycardia induced Myocardial Remodeling Rate Control Rhythm Control Warfarin (INR 2-3) Cardio Version Anticoagulated INR 2-3 for > 3 wk Hemodynamically Stable Not Anticoagulated INR < 2 for 3 wks New onset AF Hemodynamically Unstable Cardio Version Cardio version Anticoagulated INR 2-3 for > 3 wk Rate Control OP follow up in 24 to 48 hours Warfarin and Rate control Not Anticoagulated OP follow Up Or INR < 2 for 3 wk TEE/ Cardio Version Recurrent AF Minimal Symptoms Disabling Symptoms Warfarin Rate Control Warfarin Rate Control No Prevention No AAD Rx AAD Rx for Prevention Integration of several factors Age of the patient Degree of Symptoms Rate Rhythm Likelihood of success of CV Status of anti coagulation Presence of atrial thrombus Presence of co-morbidities AFFIRM Trial Rhythm RACE Trial Younger Patients - Rhythm Co-morbid older Pt - Rate Rate Anti coagulation a must Warfarin INR – above 2 - Therapeutic • • • • • • • • Atrial fibrillation is a powerful risk factor for stroke The most important treatment in AF is anticoagulation Acute cardio version is risky without anticoagulation This risk is same for electrical or pharmacologic CV TE risk increases if AF is of > 48 hours Effective Anticoagulation reduces the risk by three fold Initiation of AC can be done with Heparin or LMWH Oral direct thrombin inhibitor (Ximelagatran) no INR Male Gender, Advancing Age Rheumatic Valvular Heart Disease (RVHD) Diabetes, Hypertension , CAD, LV Dysfunction Heart Failure; Prior history of TIA/Stroke One Point • Cardiac Failure One Point • Hypertension One Point • Age more than 75 One Point • Diabetes Two Points • Stroke or TIA, STE CHADS2 Score (points) Adjusted Stroke Incidence % per year 0 1.9 1 2.8 2 4.0 3 5.9 4 8.5 5 12.5 6 18.2 Non valvular Atrial Fibrillation Rx with anticoagulation Risk Factor Stratification Risk Factors to be Ascertained High Risk Factors Prior Stroke/TIA or STE Event Moderate Risk Factors Age >75, HF, HT, EF <35%, DM Other Risk Factors Female, CAD, Thyroid, < 75 Non valvular Atrial Fibrillation Rx with anticoagulation Risk Category Recommended Treatment Age < 65; No RF Aspirin 325 mg/day Age 65-75, DM, CAD 1 RF – Give Aspirin 325 2 RF – Warfarin (INR 2.0 to 3.0) Age > 75, HT, LVD,MVD, Pr HV, Stroke, TIA, PE or More than 2 Moderate RF Warfarin (INR 2.5 to 3.5) Atrial Fibrillation Treatment with Anticoagulation 1.5% in < 60 yrs 23.5% in > 80 yrs • • • • • • • • AF is associated with risk of TE – Stroke, TIA, Perph E Anticoagulation with Heparin and Warfarin to TE Anticoagulation – risk of fatal bleeding – monitor INR Anti platelet Rx with Aspirin, Clopidogrel to TE Use the CHADS2 score to stratify the patients CHADS2 Score of zero need only Aspirin or Clopidogrel CHADS2 score of 3 or above need Warfarin / Heparin Score of 1 or 2, see H/o stroke, TIA, CAD, HT, Females Anti Coagulant Trade Name Dose Route Monitoring Heparin Beparine 5000 I.U S.C or I.V aPTT LMWH Fluxum 0.3 to 0.5 ml S.C given OD None Warfarin Uniwarfin 10-15 mg Oral daily INR Nicoumulone Acitrom 8 mg / 2-4 mg Oral daily/alt INR Phenindione Dindivan 200mg / 100mg Oral daily INR Ximalagatran Dire Thr Inh Ongoing trials None Liver toxicity • History of bleeding (2 points) • Hepatic or renal disease (1 point) • Alcohol abuse (1 point) • Malignancy (1 point) • Older age (>75 y) (1 point) • Aspirin therapy (1 point) • Reduced platelet count or platelet function (1 point) • Hypertension (1 point) • Anemia (1 point) • Genetic predisposition (1 point) • Excessive fall risk (1 point) • Patient of stroke (1 point) • • • • • • Zero points - 1.9% One point - 2.5% Two points - 5.3% Three points - 8.4% Four points - 10.4% Five or more points - 12.3% • Bleeding risk outweighs the benefit, no Anticoagulation • Pregnancy (specially 1st trimester), Elective surgery • • • • • • • • • Control of ventricular rate is a critical a component Rate-controlling agents act by AV nodal refractoriness blockers and CCBs are first-line rate control agents Given either I.V. or orally depending on the need ROAD patients we need to exert caution with Bs HR < 80 at rest; < 110 with exertion (6 min walk test, TMT) Digoxin is rarely used as monotherapy Some what useful in pts with HF and LV dysfunction Amiodarone - Class II a recommendation for rate control CCBs DLZ, VPM Digoxin Blockers Rate Control • • • • • • • • • For rapid rate control I.V. drug should be used IV CCBs (DLZ, VPM), Blocker (Metoprolol, Esmolol) Diltiazem is preferred because of least side effects For pts with sympathetic tone – Esmolol is preferred AF with heart failure; Digoxin is the choice; Not a CCB, BB Digoxin has delayed onset of action; Not effective rapidly Amiodarone is the choice in AF with CHF and BP Flecainide or Amiodarone in AF with pre excitation CCB and digoxin are contraindicated in pre excitation • Rate and Rhythm control yield similar results (AFFIRM) • Young pts who remain symptomatic after rate control • In whom rate control drugs are contraindicated • Who do not tolerate rate control drugs • Rate and Rhythm control drug combination cab be used • Class I c (Flecainide, Propafenone) are contraindicated in CAD • In CAD and Diastolic Heart Failure – Amiodarone is the choice • • • • • • • • Sinus Rhythm requires Rx of CV Risk factors, Thyroid Anti arrhythmic drugs restore Sinus Rhythm Amiodarone is safe and effective to restore SR Its adverse effects may be a problem in some Sotalol is efficacious for maintenance of sinus rhythm Requires monitoring of the QT interval & electrolytes It is contraindicated in pts with structural heart disease Catheter ablation is an alternative to drug therapy in symptomatic pts without structural heart disease AA Drug Class Dosage Indication Remarks CI / SP Amiodarone III 200-400 OD Structural HD, HF Other ADR Brady, Sparf Dofetilide III 125-250 g BD Structural HD, HF Non pediatric CKD, QT Sotalol III 80-160 BID No Structural HD Maintenance QT , TdP Flecainide Ic 50-150 BID No Structural HD PIP- Lone AF CAD, BB Propafenone Ic 150-300 OD No Structural HD PIP- young pts CAD, BB Dronedarone All 400 mg BID No Structural HD Heart Failure QT , Brady AFFIRM, CAST, CTAF, SAFE-T, RACE • Elective cardioversion and emergency cardioversion • Electrical and chemical cardioversion (Ibutilide IV CIII) • Most successful when initiated within 7 days of onset • Acute cardioversion in hemodynamically unstable • Pharmacological cardioversion no sedation or anesthesia • But, risk of ventricular tachycardia serious arrhythmia • Direct current (DC) energy cardiovertor is used • Maintain serum potassium in upper normal range • Hemodynamically unstable with AF • Severe dyspnea or chest pain with AF • Patients with pre-excitation in ECG with AF • Non responders of AF with rate control therapy • Pts without any valvular or functional heart abnormality • DC cardioversion - electrical current that is synchronized to the QRS complexes; monophasic or biphasic waves • The required energy for cardioversion is usually 100-200 J • • • • • • • • In short duration atrial fibrillation In whom the left atrium is not significantly large The success rate of cardioversion exceeds 75% Patient is sedated or anesthetized during CV Embolization is the most important complication of CV So, thrombus in the atria must be ruled out by TEE Or, Warfarin must be given for 4 weeks before CV Patient must receive Warfarin for at least 4 wks after CV • • • • • • • • Thromboembolism after CV Pulmonary edema Hypotension Myocardial dysfunction Skin burns ST- and T-wave changes on ECG Elevated levels of serum cardiac markers Synchronization of DC shock with QRS prevents serious ventricular arrhythmias • Electrical cardioversion is the most commonly used • P-CV is used if direct-current (DC) cardioversion fails or, in some cases, as a pre cardioversion strategy • Pretreatment with Amiodarone, Flecainide, Ibutilide, Propafenone, or Sotalol increases success of DC CV • This is not a choice in the hemodynamically unstable • Hemodynamically unstable patients • Those with new onset atrial fibrillation • Those with associated underlying heart disease • Those who are in heart failure • Patients older than 65 years • Patients with suspected Acute Coronary Syndrome • Other co-morbid medical problems • • • • • Reducing the chance of atrial fibrillation recurrence Reducing atrial fibrillation-related symptoms Control of ventricular rate Reducing risk of TE and Stroke Management of CV risk factors to reduce the AF recurrence and related morbidity and mortality • Anticoagulation is a must for all except ‘lone AF’ • Younger pts rhythm control, older ones rate control • AF begets AF, Sinus Rhythm begets Sinus Rhythm • Atria are transected and resutured to the critical mass • Surgical MAZE procedure is an attractive procedure • Catheter Ablation is the widely used procedure • Compartmentalization with continuous ablation lines • Catheter ablation of focal triggers of atrial fibrillation • AV node ablation & insertion of a permanent pacemaker • Percutaneous closure of the left atrial appendage to TE • Post Ablation Anti Arrhythmic Drug therapy • • • • • • • • • Atrial Fibrillation is the most common arrhythmia Evaluate for any underlying structural heart disease Classification patients and risk stratification for Rx Thrombo embolism is the main threat in a pt of AF Age is a very strong risk factor for AF as well as STE Anticoagulation with Warfarin is the main stay of Rx. Rate control with -B and CCBs is a must in all AAD for rhythm control only in selected chronic AF Cardioversion, Catheter Ablation, MAZE in selected pts