It's a comprehensive presentation of atrial fibrillation. It will be good for beginners.

1. Dr.Rajasekar Ramar - 12/26/2022
Atrial Fibrillation

3. Why NOW ?
1628
William
Harvey
first to describe fibrillation of the auricles in
animals
1693-1770
Jean Baptist
de Sénac
correlation between "rebellious palpitation" and
stenosis of the mitral valve
1785
William
Withering
brought relief to patients with atrial fibrillation
and congestive heart failure by reducing the
ventricular rate
1827
Robert
Adams
association of irregular pulses and mitral
stenosis.
1853-1925
Sir James
Mackenzie
demonstrated that a presystolic wave cannot be
seen during "pulsus irregularis perpetuus",

4. Why NOW ?
0
17500
35000
52500
70000
1945-1995
1996-2010
2011-2022
11,241
25,965
65,960

6. Why NOW
?
↑Scientific
development
↑Literacy
Improved
Healthcare
↑Average Life Span
&
↑Survival with Chronic Disease
Leads to…

8. 0
4
8
12
16
2010-2020
2030
2050
3
9
16
Expected No. in 2050?

9. Global Epidemic ???

10. Global Epidemic ???

11. Global Epidemic ???

13. Importance of Treating AFib?
0
1.25
2.5
3.75
5
Risk of STROKE
Without AF
With AF
0
0.75
1.5
2.25
3
Risk of HEART
FAILURE
Without AF
With AF
0
0.5
1
1.5
2
Risk of both
Dementia and
Mortality
Without AF
With AF

14. Atrial
Fibrillati
on
34%
VF
2%
VT
10%
SCD
3%
Conduc
tion
Disease
8%
SSS
9%
Atrial
Flutter
4%
PVC
6%
PSVT
6%
Unspeci
fied
18%
Hospitalization for Arrhythmia (USA)

15. “In the United States, hospitalizations with AF as the primary diagnosis total
>467 000 annually, and AF is estimated to contribute to
>99 000 deathsper year.”
Why Should We Treat AFib?

16. “AF is also expensive, adding approximately
$8700 per year, for a patient with AF
compared with a patient without AF.
Why Should We Treat AFib?

17. It is estimated that treating patients with AF adds
$26 billionto the US healthcare bill annually.
Why Should We Treat AFib?

19. What is AFib?
achyarrhythmia with uncoordinated atrial activation and consequently inef

20. What is AFib?
AF is a supraventricular tachyarrhythmia with
uncoordinated atrial activation and consequently
ineffective atrial contraction.

22. What Causes
AFib?
• Fibrosis
• Dilation
• Ischemia
• Infiltration
• Hypertrophy
Atrial Structural
Abnormalities :
↑ Heterogenicity
↓ Conduction
↓ Action Potential duration
↑ Automaticity
Abnormal intracellular Ca handling
Atrial Electrical Abnormalities :
Atrial tachycardia
remodeling
RAAS
activation
Inflammation
Oxidative Stress
Channelopathy
Cardiomyopathy
Hypertension
Obesity
Sleep Apnea
Hyperthyroidism
Alcohol / Drugs
Autonomic
nervous
system
activation
Atrial
tachycardia
remodeling

23. Trigger - automaticity in cells within
the myocardial tissue of the PVs
Maintenance - chaotic architecture and
electrophysiological properties of these
vesselse

24. Risk Factors:
1. Age
2. HTN
3. COPD
4. OSA
5. Obesity
6. HF
7. Valvular Heart disease
8. Cardiomyopathy
9. DM

25. Tiggers:
1. Hyperthyroidism
2. Acute pulmonary embolism
3. Myopericarditis
4. Pneumonia
5. After cardiac surgery

29. Irregularly irregular rhythm
No P waves
Absence of an isoelectric baseline

32. Investigations
1. ECG
2. C XRAY
3. Ischemia Testing
4. Basic laboratory investigations (full blood count; renal, liver; electrolytes,
including calcium and magnesium, glucose, and lipid profile)
5. TFT
6. ECHO
7. Sleep Study

34. Avoid Stroke /
nticoagulations
AFib
Management Better Symptom Control
Concomitant CV Disease
detection and Management .

35. Avoid Stroke
Better Symptom Control
Pharmacologica
l
Non-
Pharmacologica
l
Percutaneou
s
Surgical
Warfarin
DOAC

37. Pharmacologica
l
Warfarin
DOAC
Warfarin vs DOAC?
Except
mechanical heart valve of any type and location
Patients with rheumatic mitral stenosis valve area ≤1.5 cm2
CKD
bioprosthetic valve within three to six months of implantation
Cost?
Peri OP?
Pregnancy ?
Acute stroke?
Prevention of embolization prior to and after restoration o
DOACs have more favorable efficacy and safety profiles
among patients with atrial fibrillation.

38. Avoid Stroke
Better Symptom Control
Pharmacologica
l
Non-
Pharmacologica
l
Percutaneou
s
Surgical
Watchman
Device
Amplatzer
cardiac plug
Warfarin
NOAC

39. Better Symptom
Control
Rate
Control
Rhythm
Control
Drugs
AV node Ablation &
Pacemaker
Revert
Maintain
Electrical Cardioversion
Pharmacological Cardioversion
Catheter Ablation
Pharmacotherapy
Surgical Maze Procedure

40. Rate
Control
Drugs
AV node
Ablation &
Pacemaker
Beta
Blocker
ndp CCB
Digoxin
Anti Arrhythmic
drugs

41. Rhythm
Control
Revert
Maintain
Electrical Cardioversion
Pharmacological Cardioversion
Catheter Ablation
Pharmacotherapy
Surgical Maze Procedure

43. Revert
Electrical Cardioversion
Pharmacological Cardioversion
Pill in the pocket

44. Maintain
Catheter Ablation
Pharmacotherapy
Amiodarone
Dofetilide
Dronedarone
Flecainade
Propafenone
Sotalol
Disopyramide
CASTLE-AF [Catheter Ablation vs. Standard Conventional
Treatment in Patients With LV Dysfunction and AF]

46. Surgical Maze Procedure
FAST (Atrial Fibrillation Catheter Ablation Versus
Surgical Ablation Treatment)

47. Rate Control vs Rhythm Control ?
detailed discussion with the patient of the benefits and risks of each approach
Rate > Rhythm
Very elderly
patients with long-standing atrial fibrillation
markedly enlarged left atria
Rhythm > Rate 1. Failure of rate control
2. High-cardiovascular-risk patients
3. Heart failure
4. Younger patiens
5. Symptomatic AF

48. In Rhythm Control Catheter Ablation VS Medical Therapy ?
CA is associated with all-cause mortality benefit
CA reduces cardiovascular hospitalizations and recurre

49. Cardiovascular risk factor
and concomitant Disease
detection and
Management .
Lifestyle
Interventio
n
Specific
CV risk
factors
Obesity
Alcohol and
caffeine use
Physical Activity
HTN
HF
CAD
DM
OSA

50. Prevention & Screening
There is no proper screening guidelines till now…
Alcohol
Physical activity and weight loss
CONTROL: BP, DM, CAD, HF
Extra virgin olive oil ?

52. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
79 y F, HTN, HLP,
Vitals : Stable; HR : 110
Meds : Aspirin 81, Statin, Lisinopril
Excision
of LAA
ECG

53. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
71 Y M HTN, CAD,
Vitals : Unstable
Troponin : ↑
Excision
of LAA

54. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
75y F HTN, CAD s/p Stent,
Vitals : Stable; HR: 72
Meds : Metoprolol, aspirin, statin
Excision
of LAA

55. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
86 Y M HTN, HFrEF, AR, Stage 4 Ca
Vitals : Stable
Excision
of LAA

56. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
97 Y M HTN, HFrEF, MS
Vitals : Stable
Excision
of LAA

57. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
63 Y M HTN, HFrEF, AR
Vitals : Stable
Excision
of LAA

58. Heparin Warfarin DOAC Cardiovesion Rate
Control
Anti
Arhythmic
Surgical
Maze
Catheter
Ablation
Watchman
Device
64 Y M HTN, MS, DM, BPH,
Vitals : Stable
Plan : MVR in 2 days
Excision
of LAA

59. Any Questions ?

60. Game