Rate control<br />Bblockers , CCBs , digoxin are effective for rate control.<br />Do not convert AF into NSR.<br />C/I in pre excitation<br />Amiodarone for both rate and rhythm control.<br />Several side effects limits its use as first line drug.<br />Choice of drugs depends upon the clinical presentation<br />
Normal systolic function:<br /><ul><li>IV CCBs non dihydropyridine group
IV BBs --- class I recommendation</li></ul>LVD or HF :<br /><ul><li>IV digoxin or IV amiodarone –class I recommendation
In case of AV nodal blocking agents C/I </li></li></ul><li>DILTIAZEM:<br /><ul><li>Chemical defibrillator
0.25 mg /kg (15-20 mg ) given IV over 2 minutes.
Affects the pharmacokinetics of digoxin , warfarin , verapamil — reduced dose</li></li></ul><li>WPW SYNDROME<br /><ul><li>Use of AV nodal blocking agents is dangerous.
Allows the fibrillatory waves to pass freely through the bypass tract--- VF
Type Ia agents which increase refractory period of bypass tract –procainamide
Inhibit both AV node and bypass tract– type Ic and type III ibutilide or amiodarone IV to control ventricular rate.
Or else use EC</li></li></ul><li>Non pharmacologcial control of VR in AF<br /><ul><li>In case of tachycardia induced cardiomyopathy</li></ul>AV nodal ablation : if the VR in AF cannot be controlled by AV Nodal blocking agents AV nodal ablation with permanent ventricular pacemaker is an option<br /><ul><li>Agents should be tried</li></ul>Pulmonary vein isolation:<br /><ul><li>Surgically or RFA</li></li></ul><li>
What is effective rate control?<br /><ul><li>At rest HR , 80 /MIN
Whom? ------- persistent,paroxysmal</li></li></ul><li>Do all need ?<br /><ul><li>Severely symptomatic ,less severe symptomatic acute AF --- to be cardioverted…..
“restoration of SR is a reasonable goal in patients who have a first time diagnosis of AF regardless of symptoms unless some indications shows that AF has been prsent for many years before identification…….” CARDIOLOGY CLINICS
In asymptomatic to slow progression of AF </li></li></ul><li><ul><li>Duration of paroxysmal event progression of AF
WHAT DOES TRIALS SAY?<br />AFFIRM trial :<br />RACE trial :<br />AF –CHF trial<br />ALL reveal no change in mortality in both groups.<br />Treatment is individuialised<br />
AFFIRM trial : management of AF with the rhythm control strategy offers no survival advantage over the rate control strategy.anticoagualtion to be continued in this group of high risk patients .<br />ATHENA trial :a trial with dronaderone to prevent hospitalisation or death in AF<br />400mg bid dose<br />ANDROMEDA –european trial of dronedarone in moderate to severe CHF---400 mg bid<br />CAFÉ trial : canadian AF evaluation study.<br />SAFIRE –D study –doefetilide use in AF 500ug dose.<br />CRAFT <br />REL-Y TRIAL 110mg -150 mg of dabigatran.<br />RECOVER –in dvt<br />ROCKET AF –rivaroxaban<br />EINSTEIN ---vte<br />ATLAS ACS –in ACS <br />
5.WISDOM trial –withdrawal or continuation of amiodarone in successfully treated patients with persistent AF
6.w 3 fatty acids for prevention of post OP AF--- OPERA</li></li></ul><li>Recent advances<br />ACC/AHA 2010 guidelines<br />How to handle rate control therapy<br />Recently introduced antiarryhtmic drugs<br />Catheter based treatment<br />Antithrombotic therapy<br /><ul><li>No benefit of achieving strict heart rate control <80 bpm at rest <110 bpm on exercise ---class IIIevidence b
Catheter ablation is becoming the major option in treatment.
Effects of antiarryhthmic drugs are overcome by new drugs.
INR need not be monitored witndagibatran</li></li></ul><li>
Ganong<br />Samson and wright physiology<br />Guyton<br />www.emedicine.com<br />www.aha.org<br />www.atrialfibrillation.com<br />And finally I landed up in AF ---DOCTORS SYMDROME….THANK YOU for your attention<br />
Professor: define seminar<br />Student :seminar is defined as process in which one spoils his sleep for one night in an effort to make others sleep.<br />
Thank you<br />Dr.P.L.JOHN ISRAEL<br />H.O.D OF GENERAL MEDICINE<br />