Atrial Fibrillation: Rate/Rhythm Control  Non Pharmacological Management              Dr Akshay Mehta               Dr B N...
Two most important things to know Type of AFSymptoms due to AF
First Diagnosed Episode of AFParoxysmal        Persistent (> 7   Long standing   Permanent(usually          days or       ...
EHRA score of AF-related                   symptomsEHRA class               ExplanationEHRA I                   ‘No sympto...
Choosing Rate v/s Rhythm ControlTwo types of settingsAcute/UnstableNon acute/Stable
Acute/Unstable settingRate Control                          Rhythm ControlCause: underlying cond                 severe AF...
How RateControl ?
Acute/Unstable setting        Rhythm control – (Sx or hemody instab)     Pharmac cv              Electrical cv* <48 hrs   ...
ESC 2012
Recommendations foranticoagulation pericardioversion
………..recommendations foranticoagulation pericardioversion
Non Acute/Stable Setting :Rate Control     v/s Rhythm control               INCLUDES RATE CONTROL         OAC for Both
AIMS of management of AF                 patients:• Prevent complications• Reduce symptoms (palpitations, dyspnoea,  fatig...
Randomized trials comparing rate     control with rhythm control• Atrial Fibrillation Follow-up Investigation of Rhythm   ...
However….• These studies enrolled predominantly older patients (average  70 y)• Most of whom had persistent AF and heart d...
Hence… Rate control may be reasonable initial therapy in  older patients with persistent AF with mild  symptoms For youn...
When to do Rate Control ?
How to do long-term rate control
How MUCH rate control ?                              < 80, 110               Exercise test if                             ...
Rhythm Control  Rhythm control therapy is reasonable toameliorate symptoms, in paroxysmal/persistent                    AF
When to do Rhythm Control ?
AAD Therapy to maintain sinus rhythm inpatients with recurrent paroxysmal or persistent                atrial fibrillation...
Antiarrhythmic drugs v/s left atrial ablation     for rhythm control in AF ESC 2012
Catheter ablation for AF using the CARTO contact                mapping system
Recommendations for surgical      ablation of AF
Recommendations for LAAclosure/occlusion/excision - ESC 2012
Recommendation for atrioventricular     node ablation in AF patientsShould be considered When the rate cannot be controll...
Summary- management of patients with      recurrent paroxysmal AF              Recurrent Paroxysmal AF        Minimal or n...
Summary- management of patients with recurrent         persistent or permanent AF                                         ...
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Atrial Fibrillation: Rate/ Rhythm control-Non pharmacological management

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Atrial Fibrillation: Rate/ Rhythm control-Non pharmacological management

  1. 1. Atrial Fibrillation: Rate/Rhythm Control Non Pharmacological Management Dr Akshay Mehta Dr B Nanavati Hospital Asian Heart Institute
  2. 2. Two most important things to know Type of AFSymptoms due to AF
  3. 3. First Diagnosed Episode of AFParoxysmal Persistent (> 7 Long standing Permanent(usually days or Persistent (accepted)<= 48 h) requires CV) ( >1 year)
  4. 4. EHRA score of AF-related symptomsEHRA class ExplanationEHRA I ‘No symptoms’EHRA II ‘Mild symptoms’; normal daily activity not affectedEHRA III ‘Severe symptoms’; normal daily activity affectedEHRA IV ‘Disabling symptoms’; normal daily activity discontinued
  5. 5. Choosing Rate v/s Rhythm ControlTwo types of settingsAcute/UnstableNon acute/Stable
  6. 6. Acute/Unstable settingRate Control Rhythm ControlCause: underlying cond severe AF Sx orEx- pneumonia, PE, Thyroid h-dynamic instabNo severe AF Sx orh-dynamic instab pharmac cv electric cvOlder ageLarge LA
  7. 7. How RateControl ?
  8. 8. Acute/Unstable setting Rhythm control – (Sx or hemody instab) Pharmac cv Electrical cv* <48 hrs *can > 48 hrs* No electrolyte *ischemia imbalance *hypoten* No ECG *HF sign of severe *Preexcited AF with ongoing ishemia instability* Hemodynamic stable + , -
  9. 9. ESC 2012
  10. 10. Recommendations foranticoagulation pericardioversion
  11. 11. ………..recommendations foranticoagulation pericardioversion
  12. 12. Non Acute/Stable Setting :Rate Control v/s Rhythm control INCLUDES RATE CONTROL OAC for Both
  13. 13. AIMS of management of AF patients:• Prevent complications• Reduce symptoms (palpitations, dyspnoea, fatigue, and dizziness) antithrombotic therapy control of ventricular rate Rx of associated CV disease• ± Additional rhythm control therapy by cardioversion, antiarrhythmic drug therapy, or ablation therapy
  14. 14. Randomized trials comparing rate control with rhythm control• Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) : no difference in all cause mortality (primary outcome) or stroke rate• The Rate Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) trial :rate control not inferior to rhythm control for prevention of cardiovascular mortality and morbidity (composite endpoint).• The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial : in patients with an LVEF ≤35%, no difference in cardiovascular mortality (primary outcome) symptoms of congestive heart failure, or in the secondary outcomes including death from any cause and worsening of heart failure
  15. 15. However….• These studies enrolled predominantly older patients (average 70 y)• Most of whom had persistent AF and heart disease,• Follow-up extended over just a few years• Pts were at a stage where difficult to maintain sinus rhythm Hence :• Data don’t necessarily apply in young• Must not lose “window” of opportunity due to electrical and structural remodeling
  16. 16. Hence… Rate control may be reasonable initial therapy in older patients with persistent AF with mild symptoms For younger individuals, especially those with paroxysmal lone AF, rhythm control may be a better initial approach.
  17. 17. When to do Rate Control ?
  18. 18. How to do long-term rate control
  19. 19. How MUCH rate control ? < 80, 110 Exercise test if excessive heart rate is anticipated during More strict rate exercise Symptoms control RateControl 24 h ECG for safety No or tolerable Accept lenient symptoms rate control resting<110/mt
  20. 20. Rhythm Control Rhythm control therapy is reasonable toameliorate symptoms, in paroxysmal/persistent AF
  21. 21. When to do Rhythm Control ?
  22. 22. AAD Therapy to maintain sinus rhythm inpatients with recurrent paroxysmal or persistent atrial fibrillation. β-Blockers are recommended for prevention of adrenergic AF-I C & should be considered for rhythm (+ rate) control in a first episode of AF - IIa 2011 Writing Group Members et al. Circulation 2011;123:104-123 Copyright © American Heart Association
  23. 23. Antiarrhythmic drugs v/s left atrial ablation for rhythm control in AF ESC 2012
  24. 24. Catheter ablation for AF using the CARTO contact mapping system
  25. 25. Recommendations for surgical ablation of AF
  26. 26. Recommendations for LAAclosure/occlusion/excision - ESC 2012
  27. 27. Recommendation for atrioventricular node ablation in AF patientsShould be considered When the rate cannot be controlled with pharmacological agents and when AF cannot be prevented by antiarrhythmic therapy or is associated with intolerable side effects, when direct catheter-based or surgical ablation of AF is not indicated, has failed, or is rejected. IIaShould be considered for patients with permanent AF and an indication for CRT (IIa)Should be considered for CRT nonresponders in whom AF prevents effective biventricular stimulation and amiodarone is ineffective or contraindicated- IIa• In patients with any type of AF and severely depressed LV function biventricular stimulation should be considered after AV node ablation.
  28. 28. Summary- management of patients with recurrent paroxysmal AF Recurrent Paroxysmal AF Minimal or no Disabling symptoms symptoms in AF Anticoagulation Anticoagulation and rate control* and rate control as needed as needed No drug for AAD therapy * prevention of AF AF ablation if AAD treatment fails
  29. 29. Summary- management of patients with recurrent persistent or permanent AF Recurrent Persistent AF Permanent AF Minimal or no Disabling Anticoagulation and rate symptoms control* as needed symptoms in AF Anticoagulation and Anticoagulation and rate control* as rate control needed AAD drug therapy Electrical cardioversion as needed Continuous anticoagulation as needed and therapy to maintain sinus rhythm * Consider ablation for severely symptomatic recurrent AF after failure of greater than or equal to 1 AAD plus rate control
  30. 30. THANK YOU!!!

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