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  • 1. Atrial Fibrillation…. Robert Minera D.O. PGY-IV ARMC Emergency Medicine
  • 2. Atrial Fibrillation…. aka Pennington Syndrome Robert Minera D.O. PGY-IV ARMC Emergency Medicine
  • 3. Epidemiology
    • Most frequently diagnosed arrhythmia
    • Affects 2.3 million people in the US
    • Affects 1/136 people in the US
    • Incidence increases with age
    • 8% of people >80 yrs. old
  • 4. Signs and Symptoms
    • Palpitations
    • Weakness
    • Dizziness
    • Reduced exercise capacity
    • Dyspnea
    • Asymptomatic
  • 5. Etiology/Risk Factors
    • Structural heart disease
    • Chronic lung disease
    • Pneumonia
    • Hyperthyroidism
    • Alcohol use
    • Pulmonary embolism
    • HTN
    • Pericarditis
  • 6. Differential Diagnosis
    • Narrow Complex Tachycardias
      • Atrial Fibrillation
      • Atrial Flutter
      • AVNRT
      • AVRT
      • Atrial tachycardia
      • Sinus tachycardia
      • Multifocal atrial tachycardia
    SVT is a category, not a diagnosis!
  • 7. ACC/AHA/ESC
    • Paroxysmal: terminates in < 7 days
    • Persistent: fails to terminate within 7 days
    • Permanent: > 1 year
    • Lone: Individuals without structural heart disease, < 60 yrs old
  • 8. Diagnostic Testing: EKG Narrow Complex Irregularly Irregular Rapid Ventricular Rate
  • 9. Diagnostic Testing: TTE
    • To assess for structural heart disease
      • EF
      • Wall motion
      • Dilation/Hypertrophy
      • Size of right and left atrium
      • Valvular disease
      • Pericardial disease
  • 10. Chest X-Ray
    • Look for emphysema/COPD
    • Cardiac borders
    • Pneumonia
  • 11. Management
    • Rate Control
    • Rhythm Control
    • Anticoagulation
    • Unstable patients
  • 12. Rate Control
    • Why is rate control important?
      • Ischemia, MI, hypotension can occur
      • Long term: Cardiomyopathy
    • Goals
      • Rest HR < 80 bpm
      • 24 Hour (Tele/Holter) < 100 bpm average
      • HR < 110 in 6 minute walk
  • 13. Rate Control (con’t)
    • Medications
      • Metoprolol / Esmolol: IV or Oral
      • Diltiazem: IV or Oral
      • Verapamil: Oral Only
      • Digoxin: Patients with hypotension
      • Amiodarone: Also for rhythm control
  • 14. Rhythm Control
    • Indications
      • Symptoms of a-fib persistent
      • To avoid long term anticoagulation
      • Bleeding risk
  • 15. Rhythm Control (con’t)
    • Synchronized DC cardioversion
      • Emergencies/Hemodynamic instability
      • Greater efficacy than medications
    • Pharmacologic cardioversion
      • If AF < 7days – dofetilide, flecainide, ibutilide, propaferone or amiodarone
      • If AF > 7 day – dofetilide or amiodarone
  • 16. Rate or Rhythm Control?
    • AFFIRM Study: Rate versus rhythm control
      • No difference in incidence of stroke
      • Trend towards lower mortality in the rate control group
      • This is STILL a controversial topic!
      • New study focusing on rhythm conversion-
      • Ottawa Protocol
  • 17. Anticoagulation and Cardioversion
    • Afib < 48 hours:
      • Cardioversion (CV)
      • No anticoagulation indicated
    • Afib > 48 hours:
      • Anticoagulate for 3-4 weeks before CV
      • OR get TEE
      • Anticoagulate for 1 month after CV
  • 18. Anticoagulation – Long Term
    • Risk of CVA determined by CHADS2 score (CHF, HTN, >75, DM, Previous CVA x 2)
    Key Points Most patients, can wait 48 hours before starting 0-1 probably don’t need anticoagulation 5-6 should be bridged with heparin/LMWH Score Annual Stroke Risk % 0 1.9 1 2.8 2 4.0 3 5.9 4 8.5 5 12.5 6 18.2
  • 19. Management – Unstable
    • Unstable: A-fib associated with Hypotension
    • Synchronized electric Cardioversion immediately
  • 20. Key Points
    • MI is a rare CAUSE of a-fib
    • Rate control must be achieved during exercise, not just at rest
    • Not every patients needs to bridge with heparin
    • Unstable patients should immediately be cardioverted