Management and Prevention of Atrial fibrillation after Cardiovascular surgery 外科  4A ICU intern: 潘聖衛 2004/5/17
Introduction <ul><li>AF is the most common after cardiac surgery </li></ul><ul><li>Prevalence: </li></ul><ul><ul><li>40% a...
 
Etiology <ul><li>Table 2 </li></ul><ul><li>preexisting age-related degenerative cardiac changes in atrial myocardium (coll...
Prophylaxis <ul><li>Patients at greatest risk </li></ul><ul><li>Pretreatment with beta-blockers decreased incidence of AF,...
Prophylaxis <ul><li>Table 3 and pacing </li></ul>
Treatment <ul><li>Rate control is preferred unless hemodynamic unstable  </li></ul><ul><ul><li>Rate control: Beta-blocker,...
Treatment <ul><li>Table 3 and pacing </li></ul>
ACC/AHA/ESC practice guidelines <ul><li>Recommendations for Prevention and Management of Postoperative AF </li></ul><ul><l...
<ul><li>Class IIa </li></ul><ul><ul><li>2.  Restore sinus rhythm  in patients who develop postoperative AF by  pharmacolog...
 
AF after cardiac surgery stable unstable Rate control conversion Beta-blocker CCB aminodarone chemical cardioversion Elect...
<ul><li>Thanks for your attention!! </li></ul>
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Management and Prevention of Atrial fibrillation after ...

  1. 1. Management and Prevention of Atrial fibrillation after Cardiovascular surgery 外科 4A ICU intern: 潘聖衛 2004/5/17
  2. 2. Introduction <ul><li>AF is the most common after cardiac surgery </li></ul><ul><li>Prevalence: </li></ul><ul><ul><li>40% after CABG; 60% after valvular surgery </li></ul></ul><ul><li>Usually occurred 1-5 days after OP, Peak: day 2 </li></ul><ul><li>Usually a self-limited course </li></ul><ul><li>increasing rate of post-operative stroke </li></ul><ul><li>Risk factor… </li></ul><ul><ul><li>David B. Bharucha, Peter R. Kowey. Management and prevention of atrial fibrillation after cardiovascular surgery. The American journal of cardiology 2000;85:20D-24D </li></ul></ul>
  3. 4. Etiology <ul><li>Table 2 </li></ul><ul><li>preexisting age-related degenerative cardiac changes in atrial myocardium (collagen) </li></ul><ul><li>abnormalities electrophysiologic parameters </li></ul><ul><ul><li>Prolonged P-wave duration was observed to be sensivtive(83%), but not specific(43%), predictor. </li></ul></ul>
  4. 5. Prophylaxis <ul><li>Patients at greatest risk </li></ul><ul><li>Pretreatment with beta-blockers decreased incidence of AF, most effective </li></ul><ul><ul><li>40% to 20% in p’t undergoing CABG </li></ul></ul><ul><ul><li>60% to 30% in p’t undergoing valvular surgery </li></ul></ul><ul><li>Sotalol (beta-blocker and class lll agent) </li></ul><ul><li>Aminodarone 600mg 7 days preoperatively </li></ul><ul><li>Digoxin and verapamil: no effects </li></ul><ul><ul><ul><li>Fuster and Ryden et al. ACC/AHA/ESC practice guidelines. JACC October 2001:1266i-lxx </li></ul></ul></ul>
  5. 6. Prophylaxis <ul><li>Table 3 and pacing </li></ul>
  6. 7. Treatment <ul><li>Rate control is preferred unless hemodynamic unstable </li></ul><ul><ul><li>Rate control: Beta-blocker, CCB, IV aminodarone </li></ul></ul><ul><ul><li>Digoxin is less effective (post-op: high adrenergic state) </li></ul></ul><ul><li>Electrical cardioversion, if homodynamic unstable </li></ul><ul><ul><li>Not pursued because of high recurrence rate & self-limited course </li></ul></ul><ul><ul><li>Post-conversion pharmacologic therapy </li></ul></ul><ul><li>Chemical cardioversion, especially if… </li></ul><ul><ul><li>ibutilide (newer class lll), aminodarone, sotalol </li></ul></ul><ul><li>Anticoagulation (courmadin), when AF >48 h. </li></ul><ul><ul><ul><li>Fuster and Ryden et al. ACC/AHA/ESC practice guidelines. JACC October 2001:1266i-lxx </li></ul></ul></ul>
  7. 8. Treatment <ul><li>Table 3 and pacing </li></ul>
  8. 9. ACC/AHA/ESC practice guidelines <ul><li>Recommendations for Prevention and Management of Postoperative AF </li></ul><ul><li>Class I </li></ul><ul><ul><li>1. Treat patients undergoing cardiac surgery with an oral beta-blocker to prevent postoperative AF, unless contraindicated. ( Level of Evidence: A ) </li></ul></ul><ul><ul><li>2. In patients who develop postoperative AF, achieve rate control by administration of AV nodal blocking agents. ( Level of Evidence: B ) </li></ul></ul><ul><li>Class IIa </li></ul><ul><ul><li>1. Administer sotalol or amiodarone prophylactically to patients at increased risk of developing postoperative AF. ( Level of Evidence: B ) </li></ul></ul>
  9. 10. <ul><li>Class IIa </li></ul><ul><ul><li>2. Restore sinus rhythm in patients who develop postoperative AF by pharmacological cardioversion with ibutilide or direct-current cardioversion , as recommended for nonsurgical patients. ( Level of Evidence: B ) </li></ul></ul><ul><ul><li>3. In patients with recurrent or refractory postoperative AF, attempt maintenance of sinus rhythm by administration of antiarrhythmic medications, as recommended for patients with CAD who develop AF. ( Level of Evidence: B ) </li></ul></ul><ul><ul><li>4. Administer antithrombotic medication in patients who develop postoperative AF, as recommended for nonsurgical patients. ( Level of Evidence: B ) </li></ul></ul>
  10. 12. AF after cardiac surgery stable unstable Rate control conversion Beta-blocker CCB aminodarone chemical cardioversion Electrical cardioversion Persisted >48h spontaneous conversion follow up Anticoagulation TX Keep rate control maintenance No recurrence recurrence DC after >1-2mo back to the start
  11. 13. <ul><li>Thanks for your attention!! </li></ul>

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