Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.

1. Atrial Fibrillation
Detection and management
Dr. S K Agarwal
MBBS, MD, DM,FACC, CBCCT
Consultant Interventional Cardiologist
Rashid hospital
Dubai
@skacardio

2. CV morbidity and mortality associated
with AF
Event Association with AF
Death Increased mortality, especially CV mortality due to sudden
death, heart failure or stroke.
Stroke 20–30% of all strokes are due to AF. Many patients with
stroke are diagnosed with ‘silent’, paroxysmal AF.
Hospitalization 10–40% of AF patients are hospitalized every year.
Quality of life Quality of life is impaired in AF patients independent
of other cardiovascular conditions.
LV dysfunction and
heart failure
LV dysfunction is found in 20–30% of all AF patients. AF
causes or aggravates LV dysfunction. Some patients have
completely preserved LV function despite long-standing AF.
Cognitive decline
and vascular dementia
It can develop even in anticoagulated AF patients. Brain
white matter lesions are more common in AF patients than
in patients without AF.
Significance of AF

3. Diagnosis and Timely Detection
• Rhythm in ECG showing absolutely irregular
RR intervals and no discernible distinct P
waves.
• By accepted convention, an episode lasting at
least 30 seconds is diagnostic.
• Two ECGs with documentation of AF on
separate days

4. Definition of Non-valvular Atrial Fibrillation
AF in the absence of moderate to severe
mitral stenosis or mechanical heart valve

5. Patterns of atrial fibrillation
Paroxysmal AF Episodes that terminate spontaneously or are cardioverted
within 7 days; may recur with variable frequency.
Persistent AF Episodes of continuous AF that last >7 days and do not self-
terminate, including episodes that are cardioverted
after 7 days or more.
Long-standing
persistent AF
Continuous AF lasting for ≥1 year when it is decided to adopt
a rhythm control strategy
Permanent AF AF with decision to stop further attempts to restore or
maintain sinus rhythm. If rhythm-control strategy be adopted,
the arrhythmia should be re-classified as ‘long-standing
persistent AF

6. Modified EHRA symptom scale
ESC 2016 guidelines

7. Prediction of new-onset AF
1. Possible
2. Not possible
How do we predict New onset AF ?

8. HATCH score
Variable Score
Hypertension 1
Age >75 years 1
TIA or Stroke 2
COPD 1
Heart failure 2
Total 7

9. Incidence of new-onset AF in patients
with different HATCH scores
http://dx.doi.org/10.1097/MD.0000000000005597

10. Pathophysiology and Genetic Factors
• Interstitial fibrosis, alteration of gap-junctional proteins, altered
tissue refractoriness, conduction slowing, and increase in the
heterogeneity of conduction
• Epicardial fat infiltration of the adjacent atrial myocardium may
form a unique substrate in obesity
• Genetic Predisposition:
Channelopathies (long or short QT and Brugada syndromes)
Familial Atrial Fibrillation (The risk of AF was even higher in the
younger members (aged <40 years) of the families of the patients with
lone AF)
Role of sotalol and flecainide
ESC 2016 guidelines

11. Clinical factors associated with atrial
damage and a predisposition to AF
habitual vigorous exercise
AFNET/EHRA Consensus Conference 2017

12. AF risk relationship between age and
lifestyle factors
AF Obesity Endurance Inactive Moderate
Met synd. athletes normal wt. activity
Age
European Journal of Preventive Cardiology
2018, Vol. 25(15) 1642–1645

13. AF: A preventable lifestyle disease!
• overweight and obesity were associated with
an 18% and 59% higher risk of AF
• obesity seems to be more important than
physical inactivity.
European Journal of Preventive Cardiology
2018, Vol. 25(15) 1642–1645

14. Pathophysiology of obesity on the
development of AF
European Journal of Preventive Cardiology
2018, Vol. 25(15) 1642–1645

15. Left atrial reverse remodeling by Lifestyle
intervention
European Journal of Preventive Cardiology
2018, Vol. 25(15) 1642–1645

16. Screening (use of digital technology)
• Silent AF: Opportunistic, pulse palpation in clinic or
community should be conducted in people aged ≥65 y. false
diagnosis can be minimised by using a handheld ECG
• Pacemakers and defibrillators should be interrogated regularly
for AHREs.
• Embolic stroke of uncertain source / ischemic stroke: longer
term ECG monitoring (external or implantable)
(Finger probe, smartphones-Alivecor, smart watches-CRONOVO,
and fitness bands)
• Systematic ECG screening may be considered to detect AF in
patients aged >75 years, or those at high stroke risk (Class IIa,
LoE B)-ESC 2016

18. ILR

19. Atrial fibrillation definitions
• Overt AF: Episode of at least 30 s of ECG documented absolutely irregular
RR intervals with no discernable, distinct P waves, in the presence of
symptoms typically associated with AF (i.e. palpitations, shortness of
breath, lightheadedness, chest pain, presyncope, or syncope)
• Asymptomatic/clinically silent AF: Episode of at least 30 s of ECG documented
absolutely irregular RR intervals with no discernable, distinct P waves, in the
absence of symptoms typically associated with AF
• AHRE: Episodes of at least 5 min of AT/AF with an atrial rate >180 bpm,
detected by the continuous monitoring of CIEDs
• Subclinical AF: Episodes of AT/AF with duration between 5 min and 24 h,
detected in patients without clinical history or clinical symptoms of AF
Europace (2017) 19, 1589–1623

20. Management of AHRE
National Heart foundation Australia 2018

21. Managing AHRE
Europace (2017) 19, 1589–1623

22. Embolic Stroke of Uncertain Source
ESUS
• Holter monitoring: 24-48 hours -poor gain
• External rhythm recording devices: 30 days-
but data show that a substantial proportion of
AF occurs beyond the first 30 days following
an event.
• Implantable loop recorders: 3 years of
continuous monitoring (CRYSTAL-AF trial-3yrs
HR = 8.8)

23. Diagnostic work up
• 12-lead ECG
• Hb, Creatinine, TSH, electrolytes, INR, PT
• hs-cTn, NT-proBNP
• Transthoracic echocardiogram
VHD-MS or MR
LA size and volume
LV function
• TOE

24. Normal values of LA size
J Am Coll Cardiol 2006;47:1018 –23)
men and women
N mild moderate severe
Maximum LA volume/BSA(mL/m2) 16–34 35–41 42–48 >48
ACC/AHA/ESC echo guidelines

25. Detection and management of risk
factors and concomitant diseases
• HT, DM, HF, VHD, smoking and alcohol excess
• Screening by Polysomnography and management of sleep
apnoea in patients with recurrent symptomatic AF
• maximal compliance with CPAP therapy if the apnoea–
hypopnea index was ≥15/hour
• Intensive management of weight— target BMI <27 in Obese
• Aerobic exercises to reduce the AF burden.
Treatment of these risk factors reduces symptom burden
and increases the likelihood of maintaining sinus rhythm
Risk factor management represents the ‘fourth pillar’ in AF
management

26. Obesity and AF
• The response is graded—the greater the
weight loss, the more the likelihood that the
sinus rhythm will be maintained

27. Three pillars of AF management

29. Rate vs. Rhythm control
Factors favouring a strategy of rate control over rhythm control
• background therapy for nearly all AF patients
• choice to reduce symptoms in patients for
whom risks of restoring sinus rhythm
outweigh benefits,
or in those in whom advanced rhythm control
fails.

30. Arrhythmia management—acute rate control
Secondary causes of rapid
ventricular response including
sepsis, PE, and thyrotoxicosis—
must be excluded.
National Heart foundation Australia 2018

31. Arrhythmia management—long-term
rate control
• Β-blockers and non-dihydropyridine calcium channel antagonists
should be the first-line agents.
• Digoxin: use it, if suboptimal rate control on, or contraindications to
first-line agents. Monitor serum concentration with goal of
maintaining levels of <1.2 ng/mL.
• Calcium antagonists should be avoided in patients with LV-EF <40%.
• Amiodarone: X
• Sotalol or flecainide: X
• Documentation of the adequacy of ventricular rate control (<110
bpm) at rest and with moderate exertion
• Regular clinical surveillance for emergent CMP or overt HF should
be performed during long-term follow-up
• If pharmacological rate control fails, catheter ablation of the AV
node should be considered after PPI

32. Rate vs. Rhythm control
Factors favouring a strategy of rhythm control over rate control
• Patient preference
• Highly symptomatic or physically active young patients
• Difficulty in achieving adequate rate control
• LV dysfunction (mortality benefit)
• Paroxysmal or early persistent AF
• Absence of severe atrial enlargement
• Acute AF

33. Effect on Rhythm vs. Rate Control Therapy
on Mortality Over Time
Arch Intern Med2012; 172: 997
HR=0.77

34. Arrhythmia management—acute
rhythm control
• Electrical cardioversion: in hemodynamically unstable patients
or pharmacological rhythm control fails—in hemodynamically
stable patients
• Flecainide IV or PO, for rapid conversion to sinus rhythm, in
patients without LV systolic dysfunction, moderate LVH, or
CAD.
• Amiodarone IV for delayed conversion to sinus rhythm in
patients with structural heart disease, HF, CAD.
• Success rates-flecainide 55-85%, and for amiodarone 35-90%,
rate of success in first 3-5 hrs. (50 vs. 22%).
• Sotalol: limited efficacy for acute rhythm conversion.
Consideration of thromboembolic risk in all patients

35. Drugs used for cardioversion of AF
Vernakalant is not approved in the USA and ranolazine is not approved anywhere for this
indication. Ibutilide is only sporadically approved outside the USA

36. Choice of pharmacological agent for
cardioversion in an acute setting
IIA
Class I Class I
Class IIA

38. Arrhythmia management—long-term rhythm control
• β-blockers
• Flecainide + AV nodal blocking agent
• Amiodarone
• Sotalol (close monitoring of QT interval)
Amiodarone is superior over other AADs in
maintenance of sinus rhythm but with side effects
No evidence that rhythm control is associated with
decreased stroke risk and mortality

40. Rhythm control strategy-role of
non AADs
ACEI and ARB
• Should be considered for prevention of new onset AF in
patients of HF and ↓ LVEF (IIAa)
• Should be considered for prevention of new onset AF in
patients of HT specially with LVH (IIAb)
• Pretreatment may be considered in patients of recurrent AF
undergoing electrical cardioversion and receiving AAD (IIBb)
• Not recommended for secondary prevention in patients
without any underlying heart disease (III-no benefit)
ESC 2016

41. Arrhythmia management—percutaneous catheter AF ablation
Catheter ablation should be considered for symptomatic
paroxysmal or persistent AF refractory or intolerant to at least one
Class I or III antiarrhythmic medication.
Surgical management of AF in context of concomitant cardiac
surgery
Surgical ablation of AF to restore sinus rhythm in the context of concomitant
cardiac surgery may be considered for patients with symptomatic
paroxysmal, persistent or long-standing persistent AF.

42. AF morbidity
• AF is independently associated with an
increased long term risk of stroke, heart
failure and all-cause death and often leads to
an impaired quality of life
• Between 10% and 30% of patients with AF are
admitted to hospital each year for CV and
non-CV causes

44. Confusion in ESC guidelines over stroke prevention

45. Stroke prevention—predicting stroke risk
• CHA2DS2-VA score—the sexless CHA2DS2-
VASc score
• CHA2DS2-VA score should be re-evaluated yearly
in low-risk patients who are not anticoagulated
National Heart Foundation of Australia 2018
Easy to remember by
everybody
NO mistakes

47. Ziad Hijazi et al, EHJ 2016

48. Ziad Hijazi et al, EHJ 2016

50. Managing patients with CHA2DS2VA score 1

53. ‘Reversible’ or ‘Transient’ AF
• Postoperative state
• Acute illness (e.g. sepsis or metabolic
disturbances)
• Pericarditis
• truly self-limiting AF

54. Arrhythmia Management for Post-
operative AF
• incidence of 8–50%, depending on the type
and site of the surgery
• evidence to support rhythm control versus
rate control in this population of patients is
lacking

55. AF management in Athletes
• Endurance sports: 20%–30% increased risk
among athletes
• Increase in parasympathetic tone &
development of an arrhythmogenic substrate
• Rate control can be difficult due to the
baseline bradycardia
• Rhythm control better as it has less impact on
exercise performance

57. ESC 2016

58. Digital technology into clinical practice
ESC apps

59. Digital technology into clinical practice

60. Patient #1
• 54 y, male, HTN, Smoker 1 pack/day for more than 30
years, no DM, No stroke / TIA
• H/o Paroxysmal AF on oral amiodarone and ? Blood
thinner
• Presented with symptoms of angina
• Hb 15.2, S Cr 0.9, Trop 5, 8, 8. NT-proBNP 27, Total S
chol 173, LDL 134, TG 108, HDL 31, HBA1c 5.8
• CAG: normal CAG with catheter induced spasms in
mid LAD that resolved after GTN.

61. ECG

62. Patient #1 scores
• The ABC-stroke risk score: Predicted one year
stroke/SE risk = 0.31% (normal hs-cTnT and
NT-proBNP)
• CHA2DS2VA score is 1
Decision for NOAC?

63. Patient #2
• 65 y, male, DM, HT, shortness of breath, no previous stroke,
• HR 40-140 bpm
• Hb 14.3, S Cr 0.9, HBA1c 7.9, Trop 17, 15, 19, NT-proBNP 346,
T S. choles 114, TG 100, HDL 33, LDL 73
• Echo: Normal Size cardiac chambers. Normal LV mass, Normal
LV systolic fucntion. EF-- 60--65%, Grade I diastolic
dysfunction. Normal valves and flows. TR--Trvial . ESPAP--28
mmhg.
• CAG done on 4/11/2018-Non obstructive CAD (20-30% plaque
in LAD).
Q. Risk stratification for stroke, bleeding; need for antiplatelets, need for β-blockers

64. ECG
• The ABC-stroke risk score: Predicted one year stroke/SE risk = 0.84%
• CHA2DS2VA score is 3 (HT, DM, Age)

65. @skacardio