2. Definition
• AF is characterised by disorganised, rapid, and irregular atrial
activation with loss of organized atrial mechanical contraction
and with an irregular ventricular rate that is determined by AV
nodal conduction
3.
4. RISK FACTORS
• INCREASING AGE
• HYPERTENSION
• DIABETES MELLITUS
• MI
• VHD
• HF
• OBESITY
• OBSTRUCTIVE SLEEP APNEA
• CARDIOTHORACIC SURGERY
• SMOKING
• EXERCISE
• ALCOHOL
• HYPERTHYROIDISM
• INCREASED PULSE PRESSURE
• EUROPEAN ANCESTRY
• FAMILY HISTORY
• GENETIC VARIANTS
• ECG- LVH
• 2D ECHO
– LA ENLARGEMENT
– DECREASED LV FRACTIONAL SHORTENING
– INCREASED LV WALL THICKNESS
• BIOMARKERS
– CRP
– BNP
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016
16. Vitals ?
Hemodynamically unstable
Hypotension
Cardiac ischemia
Pulmonary edema
DC cardioversion
Start anticoaguation immediately
and continued for 4weeks
f/u after 4weeks to decide for
long term anticoagulation
New onset AF
DC Cardioversion
150 to 200 J to start with,
may go up to 360J
Highly effective (95 %)
If fails, start Ibutilide infusion
before next shock
17. Vitals ? • <48hrs – cardioversion f/b
3-4weeks anticoagulation
• >48hrs/not known
early cardioversion after
excluding thrombus by TEE
3-4 weeks anticoagulation f/b
cardioversion and anticoagulation
• Electrical cardioversion is more
effective than pharmacologiacal
New onset AF
Hemodynamically stable
AF with FVR
Ventricular Rate control
Cardioversion
19. Ventricular Rate control
What are the drugs ?
How to choose ??
Dose Side effects
Metoprolol 2.5-10mg IV
100-200mg daily oral
Bradycardia, AV block,
lethargy, headache,
upper respiratory tract
symptoms
Carvedilol 3.125-50mg BD
Nevibolol 2.5–10 mg OD
Diltiazem 15-25 mg bolus IV
60-120mg TDS
dizziness, lethargy,
headache, edema
Digoxin 0.0625–0.25 mg OD gastrointestinal
Upset, arrhythmia
Amiodarone 200 mg daily Pulmonary toxicity,
thyroid dysfunction,
corneal deposits
20.
21. Rhythm control
• What are the Drugs
Dose Side effects
Propafenone Oral 150-300 TDS Arrhythmia, blurring
of vision
Flecainide 100-150mg BD Arrhythmia,
confusion
Sotalol 80-160mg BD Arrhythmia
Amiodarone IV -15mg/min x 10min, 1mg/min
x 3hrs, 0.5mg/min up to 24 hrs
Oral- 600 mg in divided
doses for 4 weeks, 400 mg
for 4 weeks, then 200 mg
once daily
Arrhythmia
Lung disease
Corneal deposit
Thyroid disorder
Dronedarone 400mg BD Arrhythmia,
transient rise in Cr.
24. Amiodarone is most effective,
In view of extracardiac adverse effects, should be
kept as last resort in recurrent AF/AF with heart
failure
25. Catheter ablation
Indications-
• symptomatic persistent AF
not responding to AAD
• Can be considered as first line
therapy in young symptomatic AF
considering patient choice, risk, benefit, side effects of AAD
Challenges-
• Arrhythmia substrate is poorly understood, widespread,
variable between patients, progressive
recurrence
29. Oral anticoagulants
VKA
INR monitoring
Drug interaction
Delay in onset and weaning of action
Narrow therapeutic range
NOAC (Non VKA Oral
Anticoagulants)
• Rivaroxaban
• Apixaban
• Edoxaban
• Dabigatran
Usually preferred over VKA
Not recommended in mechanical
heart valve and mod-severe MS
Renal dose modification
High cost
30. Secondary prevention
TIA- start anticoagulation after 1
day
Stroke- start anticoagulation
after 3-12 days considering
severity of stroke
31. Risk of bleeding- HASBLED score
Should be used as cautionary “yellow flag” for more stringent
monitoring with more severe score
32. Left atrial appendage occlusion/exclusion
• In case of contraindication to long term anticoagulation
• Surgical excision or closure by suturing/stapling is successful
only in 40% of cases
• Post op TEE should rule out thrombus before discontinuation
of anticoagulation
• Percutaneous left atrial appendage occlusion device- newer
method (LAAO)
• Non inferior to warfarin
(PROTECT-AF trial)
33. References
• AHA guidelines for AF 2014 and 2019 update
• ESC guideline for AF 2016
• Harrison’s Internal medicine 21st edition
• UpToDate 2022
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES
2016
