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Management of Atrial Fibrillation ♦ Assess the need to convert to sinus rhythmCauses of Atrial Fibrillation Physical ExamCardiac ♦ Valvular dz – MR, MS ♦ Sick sinus syndrome ♦ confirm AF (4 signs) ♦ IHD ♦ Post-cardiac surgery o IR IR pulse ♦ HPT ♦ Peri-/myo-carditis o Single flicker JVP - absence of ‘a’ wave ♦ Post MI ♦ Pre-excitation syndrome o pulse deficit ♦ CCF ♦ Acute pul. Embolism o varying loudness of 1st heart sound ♦ ASD ♦ Lone AF (no known ♦ signs of underlying causes of AF– BP, goiter and signs of thyrotoxicosis, ♦ Cardiomyopathy etiology or structural heart auscultation for murmurs (MR/MS) dz. Dx of exclusion) ♦ complications – CCF, previous strokeNon-Cardiac ♦ Hyperthyroidism ♦ DM ♦ Sepsis esp pneumonia ♦ Alcohol Investigations ECG ♦ to document AF, any evidence of MI, LVH/LAHMorbidities of AF CXR ♦ chamber size, heart failure♦ ↓ cardiac output – malaise and effort intolerance FBC♦ aggravation of MI and heart failure U/E♦ ↑ risk of Thromboembolism and stroke TFT ♦ hyperthyroidism Transthoracic ♦ structural HD (CMP, valvular dz, intracardiac shunt, pericardialTypes of AF: echocardiogram HDz),♦ 1st detected episode - may not need tx if episode is brief/ known reversible cause (TTE) ♦ chamber sizes♦ Acute AF – detected within 24-48h, has high chance of pharm/electrical cardioversion ♦ LV size and function.♦ Paroxysmal AF – AF lasting less than 7 days Additional Invxs♦ Persistent AF – >7 days 24h Holter ♦ Quantify freq & duration of symptomatic & asymp. AF episodes♦ Permanent AF – previous attempts to restore sinus rhythm have failed/ AF lasted >1y. ♦ Look for sinus node dysf(x) or sick sinus syndrome The probability of successful cardioversion is very low ♦ Assess adequacy of rhythm or rate control ♦ Assess time of onset of AF (eg night in vagally-mediated AF)Clinical Presentations ♦ Identify PTs with frequent atrial ectopics & nonsustained atrial♦ Palpitations tachycardia suitable for catheter ablation♦ CP Transesophageal ♦ Gives better visualization of LA thrombus cf TTE)♦ Dyspnoea echocardiogram ♦ Use before elective cardioversion in PTs w/o prior 3wks♦ Fatigue (TEE) warfarin♦ Light headedness Exercise stress test ♦ Assess PT with AF ppted by exertion, IHD or MI♦ Syncope ♦ Routinely done for PTs ≥40YO or with significant coronary risk♦ Cxs of AF – heart failure, haemodynamic impairments, stroke factors.♦ Asymptomatic (25%) Electrophysiological ♦ For PTs w hx of syncope to exclude sick sinus syndrome and study (EPS) Wolff-Parkinson-White syndromeEvaluation of AF♦ stable or unstable Management of AF:♦ confirm diagnosis of AF with 12 lead ECG ♦ Aims: • Improve symptoms♦ classify type of AF o Control ventricular rate • Reduce TE stroke risk♦ determine underlying cause/factors contributing to AF (eg structural and ischaemic o Reestablish sinus rhythm • Prevent cardiac remodeling HDz, estimating LVEF, valvular HDz, CMP, HPT) o Anticoagulate to prevent Thromboembolism and hence HFailure & CMP♦ look for complications of AF♦ determine risk of future complications, i.e. stroke, from AF Unstable: o HTN/ old age/ IHD/ heart failure / previous stroke/ DM o immediate sync. Cardioversion♦ Assess adequacy of control of ventricular rate during AF o f/u with anticoagulation therapy for 4 weeks
Stable: a) Acute AF (<48h) ♦ Can be cardioverted (pharm/electrical) without prior long-term anticoagulation Rhythm Control: ♦ Give IV heparin before proceeding ♦ Spontaneous cardioversion occurs in 50-70% of PTs w/in 24 to 48 hrs, but unlikely to ♦ And switch to oral, maintain INR at 2-3 for 4 weeks whatever the outcome occur if AF persisted for > a week. Drug/electrical cardioversion will be necessary. ♦ Success rate of cardioversion decrease as duration of AF increase, therefore perform b) Persistent/ Recurrent Paroxysmal AF early If minimal symptoms, ♦ Problems: failure in maintenance of sinus rhythm in >50% of PTs, significant SE of 1) Rate control drugs used o Beta-blocker o Ca blockers e.g. diltiazem/ verapamil ♦ Pharmacological Cardioversion: o Digoxin (esp if concurrent HF) Drug Comments SE o Sotalol Class IC arrhythmics ♦ Contraindications ♦ conversion to atrial flutter 2) Assess for risk of thromboembolism and anticoagulate as necessary (propafenone 300- - IHD ♦ ventricular tachycardia This is the recommended management for most patients, unless acute onset (<48h), or 600mg PO stat, - CCF ♦ enhanced AV nodal symptomatic, or complicated flecainide150-200mg - Lt vent dysf(x) conduction PO stat) - major conduction ♦ CCF disturbances c) Symptoms/ complications (e.g. syncope, heart failure, stroke) Amiodarone ♦ Takes days to wks for onset ♦ Hepatotoxic ♦ Rate control initially followed by cardioversion, with anticoagulation (600-800mg/day PO) ♦ Safe for PT with structural heart ♦ Thyroid dysfunction ♦ Then, o anticoagulate for 3 weeks with warfarin (keep INR 2-3) before cardioversion dz or heart failure ♦ GI upset ♦ Monitor LFT & TFT 6 mthly for SE ♦ Bradycardia ♦ Amiodarone ♦ Flecainide ♦ Torsades de pointes ♦ Propafenone ♦ polyneuropathy o Alternatively, do TEE to look for LA thrombus. If none, give IV Heparin and Dofetilide & ibutilide ♦ perform DC cardioversion w/o prior anticoagulation. Quinidine ♦ Hypotension ♦ Post cardioversion, maintain INR at 2-3 for 4 weeks ♦ Torsades de pointes ♦ Maintenance of sinus rhythm (Flecainide, propafenone, sotalol, amiodarone) Sotalol ♦ NOT for cardioversion ♦ Torsades de pointes ♦ Only for maintaining sinus rhythm ♦ CCF AF ♦ Exacerbation of COPD ♦ Electrical cardioversion: Unstable Stable o PT must be fasted and sedated, with good IV access and airway Mx o Check electrolyte and anticoagulation status ♦ Sync cardioversion Monophasic AF 200 joules, increments up to 360 joules ♦ 4 wks anticoagulation Atrial flutter 50 joules Biphasic AF 100 joules initially o Cxs: Thromboembolism, arrhythmia, myocardial injury, heart failure, skin burns. st 1 episode / Acute AF (<48hrs) Persistant / recurrent paroxysmal AF ♦ Other non-pharmacological rate control therapies♦ Pharm / electrical cardioversion w/o prior anticoagulation o Permanent Pacing♦ 4 wks anticoagulation o Catheter ablation – for PTs with paroxysmal AF due to atrial ectopics, PT with♦ long-term anticoagulation not necessary SVT or atrial flutter o Surgical ablation – “Maze” procedure: consider concomitant Sx ablation in PTs going for open heart Sx for valvular, ischaemic or congenital heart dz. Asymptomatic Symptomatic / complicated ♦ Maintenance of Sinus Rhythm ♦ Rate control ♦ Rate control & anticoagulation o Flecainide, propafenone and sotalol are first line drugs ♦ Long-term anticoagulation ♦ Cardioversion & maintain sinus rhythm o Amiodarone superior to previous drugs, but last choice of drug due to long term ♦ Long term anticoagulation extracardiac SE. • Treat ppt factor if present • Failure of drug therapy to achieve rate control or maintain sinus rhythm – consider pacemakers, defibrillator or catheter ablation
o Choice of drug in heart dz: Heart failure: use amiodarone ♦ Contraindications to anticoagulation CAD: use sotalol ♦ Significant bleeding or fall risk ♦ PT unlikely to comply with diet & HPT with LVH ≥1.4cm: use amiodarone ♦ Recent surgery / trauma monitoring regimen ♦ Thrombocytopenia ♦ Active peptic ulcer dzRate Control:♦ Similar efficacy to rhythm control, but drugs used are safer and there is no problems ♦ Antithrombotic strategies wrt maintenance of sinus rhythm Any high-risk factors present Long-term oral anticoagulation (target INR2.5;♦ Pharmacological rate control: >60YO with one other range 2.0-3.0) Drug Comments SE moderate risk factor β-blockers ♦ First line Rx ♦ Bronchoconstriction. CI in <60YO + one moderate risk Either aspirin 100mg/day or warfarin depending on (propranolol, atenolol, ♦ Caution in PTs with heart asthma factor PT preference, risk of blding and access to sotalol) failure ♦ Heart failure 60-75YO with no risk factor anticoagulation monitoring ♦ Hypotension Male >75 with no risk factor ♦ Heart block Low risk or warfarin is CI Aspirin (100-300mg/day). Alternatives: ticlopidine, ♦ Bradycardia clopidogrel, dipyridamole CCB (verapamil, ♦ IV CCB useful in ♦ Hypotension <60YO with no risk factors & Long term aspirin or no Rx diltiazem) emergencies ♦ Heart block normal left atrial size ♦ Preferred over β-blockers ♦ Heart failure *always consider PT factors in determining target INR level (eg fall risk in elderly, recurrent in PT with COPD TE events despite anticoagulation, prosthetic heart valves) & modify Rx accordingly ♦ Caution in PTs with heart failure ♦ Monitoring: wkly INR initially, then 6-8wkly once INR stabilizes. Digoxin ♦ Good for PT with heart ♦ Digitalis toxicity ♦ Adjustment of warfarin dose: failure ♦ Heart block o after change in drugs that interact with warfarin (eg amiodarone) ♦ Caution in elderly and PT ♦ Bradycardia o surgery (stop warfarin for 5 days prior to surgery) with renal dysf(x) Amiodarone ♦ Good for PT with heart ♦ Thyroid dysfunction failure ♦ Hepatotoxicity ♦ Not first line due to SEs – ♦ Torsades de pointes require monitoring of LFT ♦ Warfarin & digoxin and TFT interaction *combination therapies are possible eg digoxin & β-blockers♦ Non-pharmacological rate control: Permanent pacing Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, AV nodal ablation & permanent pacing: o=UCSI University, School of Medicine, KT- Campus, Terengganu, ou=Internal Medicine Group, email@example.com Reason: This document is for UCSI year 4 students.Anticoagulation: Date: 2009.02.24 10:15:03 +0800♦ Prevent thromboembolic Cxs eg stroke & peripheral arterial thromboembolism♦ Risk factors High risk factors ♦ Prior stroke/ TIA/ systemic embolism ♦ Prosthetic heart valve ♦ Rheumatic mitral stenosis ♦ >75YO Moderate risk factors ♦ 60-75YO ♦ LVEF ≤35% ♦ HPT ♦ DM ♦ CCF ♦ Thyrotoxicosis ♦ Coronary artery dz Low risk factors ♦ <60YO