1. The document discusses classification, management, and treatment of atrial fibrillation. It describes classification as paroxysmal, persistent, or permanent based on episode duration.
2. For stable patients, the first steps are evaluation, rate control if needed, and decision on cardioversion. For unstable patients, urgent cardioversion may be required. Electrical cardioversion is preferred but drugs can be used.
3. Anticoagulation for at least 3 weeks prior to and 4 weeks after cardioversion is recommended for episodes over 48 hours. For episodes under 48 hours, practices vary from anticoagulation in all to risk-based approaches.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
For each patient with AF, the two principal goals of therapy are symptom control and the prevention of thromboembolism.
Rate- and rhythm-control strategies improve symptoms, but neither has been conclusively shown to improve survival compared to the other.
Acute heart failure (AHF) is defined as rapid onset of new or worsening signs and symptoms of heart failure. It represents a life-threatening condition requiring treatment for fluid overload and hemodynamic compromise. Presentation may be initial diagnosis with symptoms and signs of AHF or acute decompensation of pre-existing cardiomyopathy. Hemodynamic instability results from disorders of the myocardium, valves, conduction system or pericardium, in isolation or combination. Potentially treatable causes, e.g. acute coronary syndromes, must be diagnosed and managed early for restoration of function.
Physiological changes associated with AHF result in reduced cardiac output and end-organ hypoperfusion. Once potentially treatable causes are managed, stratification of patients by clinical presentation guides further therapeutic intervention. AHF patients can be categorized as either ‘wet’ or ‘dry’ by clinical fluid status assessment, and either ‘cold’ or ‘warm’ according to perfusion status. In combination, these features identify four patient groups (‘warm-wet’, ‘warm-dry’, ‘cold-dry’, ‘cold-wet’) that guide therapy and facilitate prognostication. ‘Warm-dry’ patients rarely require intensive care for AHF treatment but may benefit from escalation of oral therapeutic regimen. Patients who examine as ‘cold-dry’ may benefit from fluid challenge, and/or inotropic agent infusion. ‘Warm-wet’ patients present with predominantly congestive or hypertensive symptoms which benefit from diuresis and vasodilatation. Patients who present ‘wet-cold’ with normal blood pressure (SBP >90) may benefit from vasodilators and diuretics, with inotropic agents for refractory symptoms. Hypotensive ‘wet-cold’ patients (classic cardiogenic shock) require inotropy with or without vasopressor agents, effective diuresis and early consideration of mechanical circulatory support (MCS).
Definitive therapies for AHF depend on underlying cause, and may include coronary artery intervention, valve repair, rhythm control to restore atrio-ventricular synchrony or management of pericardial tamponade. Patients with severe AHF not responsive to standard therapies should be considered for temporary MCS while candidacy for more durable option is explored by the multi-disciplinary team.
Atrial fibrillation (AF) is the most frequently diagnosed cardiac rhythm disorder. It affecting 2.5 million people in the United States, and may be associated with an increased risk for death, congestive heart failure, and stroke. Our cardiac electrophysiologist will review the latest treatment options for patients with AF, including recent advances in pharmacologic therapy to keep patients heart rhythms normal. He also will discuss catheter ablation to eliminate sources of AF and anticoagulation to prevent thromboembolic strokes. Presented by Summit Medical Group cardiologist, Roy Sauberman, MD, FACC
For each patient with AF, the two principal goals of therapy are symptom control and the prevention of thromboembolism.
Rate- and rhythm-control strategies improve symptoms, but neither has been conclusively shown to improve survival compared to the other.
Acute heart failure (AHF) is defined as rapid onset of new or worsening signs and symptoms of heart failure. It represents a life-threatening condition requiring treatment for fluid overload and hemodynamic compromise. Presentation may be initial diagnosis with symptoms and signs of AHF or acute decompensation of pre-existing cardiomyopathy. Hemodynamic instability results from disorders of the myocardium, valves, conduction system or pericardium, in isolation or combination. Potentially treatable causes, e.g. acute coronary syndromes, must be diagnosed and managed early for restoration of function.
Physiological changes associated with AHF result in reduced cardiac output and end-organ hypoperfusion. Once potentially treatable causes are managed, stratification of patients by clinical presentation guides further therapeutic intervention. AHF patients can be categorized as either ‘wet’ or ‘dry’ by clinical fluid status assessment, and either ‘cold’ or ‘warm’ according to perfusion status. In combination, these features identify four patient groups (‘warm-wet’, ‘warm-dry’, ‘cold-dry’, ‘cold-wet’) that guide therapy and facilitate prognostication. ‘Warm-dry’ patients rarely require intensive care for AHF treatment but may benefit from escalation of oral therapeutic regimen. Patients who examine as ‘cold-dry’ may benefit from fluid challenge, and/or inotropic agent infusion. ‘Warm-wet’ patients present with predominantly congestive or hypertensive symptoms which benefit from diuresis and vasodilatation. Patients who present ‘wet-cold’ with normal blood pressure (SBP >90) may benefit from vasodilators and diuretics, with inotropic agents for refractory symptoms. Hypotensive ‘wet-cold’ patients (classic cardiogenic shock) require inotropy with or without vasopressor agents, effective diuresis and early consideration of mechanical circulatory support (MCS).
Definitive therapies for AHF depend on underlying cause, and may include coronary artery intervention, valve repair, rhythm control to restore atrio-ventricular synchrony or management of pericardial tamponade. Patients with severe AHF not responsive to standard therapies should be considered for temporary MCS while candidacy for more durable option is explored by the multi-disciplinary team.
Atrial fibrillation (AF) is the most frequently diagnosed cardiac rhythm disorder. It affecting 2.5 million people in the United States, and may be associated with an increased risk for death, congestive heart failure, and stroke. Our cardiac electrophysiologist will review the latest treatment options for patients with AF, including recent advances in pharmacologic therapy to keep patients heart rhythms normal. He also will discuss catheter ablation to eliminate sources of AF and anticoagulation to prevent thromboembolic strokes. Presented by Summit Medical Group cardiologist, Roy Sauberman, MD, FACC
Atrial fibrillation (afib) is a heart rhythm disorder (arrhythmia). It increases your risk of having a stroke and can affect your quality of life. There are many treatment options for patients with atrial fibrillation (afib).
In order to decrease the burden of the symptoms from afib, we can use medications or procedures - catheter ablation.
Patients with afib have a 5 fold higher risk of having a stroke. Traditionally blood thinners are used to decrease that risk. A new option available as an alternative to blood thinners is the Watchman left atrial appendage closure device.
- Describe the basic characteristics of new oral anticoagulants (OACs)
- Recognize potential candidates for new anticoagulants for atrial fibrillation and treatment of venous thrombosis
Introduction to afib, Epidemiology of afib, etiology of afib, Clinical presentation of people with afib, Investigation and management
AF related outcomes and complications and differential Diagnosis
During atrial fibrillation, the heart's upper chambers — called the atria — beat chaotically and irregularly. They beat out of sync with the lower heart chambers, called the ventricles. For many people, AFib may have no symptoms. But AFib may cause a fast, pounding heartbeat, shortness of breath or light-headedness.
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.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial
Fibrillation
http://www.uptodate.com/contents/management-of-new-onset-atrial-
fibrillation
http://www.uptodate.com/contents/atrial-fibrillation-cardioversion-to-sinus-
rhythm
Ferri's Clinical Advisor 2015
4. CLASSIFICATION
Multiple classification schemes have been used in the past to
characterize AF. The current classification scheme (divided into three
major types) used by the ACC/AHA guideline committee is as follows:
Paroxysmal AF—more than one episode of AF that terminate
spontaneously within 7 days (most episodes last less than 24 hr)
Persistent AF—episodes of AF that last longer than 7 days and may
require either pharmacologic or electrical intervention to terminate
Permanent AF—AF that has persisted for longer than 1 yr, either
because cardioversion has failed or because cardioversion has not
been attempted
5. CLASSIFICATION
• In addition to the previous AF categories, which are mainly defined
by episode timing and termination, the ACC/AHA/ESC guidelines
describe additional AF categories in terms of other characteristics of
the patient:
• Lone atrial fibrillation (LAF)—generally refers to AF in younger
patients (<60 yr old) who have normal echocardiographic findings
• Nonvalvular AF—absence of rheumatic mitral valve disease, a
prosthetic heart valve, or mitral valve repair
• Secondary AF—occurs in the setting of a primary condition that may
be the cause of the AF, such as acute myocardial infarction, cardiac
surgery, pericarditis, myocarditis, hyperthyroidism, pulmonary
embolism, pneumonia, or other acute disease. It is considered
separately because AF is less likely to recur once the precipitating
condition has resolved.
7. MANAGEMENT
The first step in management is to determine whether the patient is
stable or not…
-Look for any hemodynamic instability such as hypotension
-Is the patient responsive?
-Are there any mental status changes?
-are symptoms persistent and unbearable?
9. URGENT MANAGEMENT
Three circumstances for which urgent or emergent cardioversion may
be needed include:
●Active ischemia (symptomatic [eg, angina] or electrocardiographic
evidence).
●Evidence of organ hypoperfusion (eg, cold clammy skin, confusion,
acute kidney injury).
●Severe manifestations of heart failure (eg, pulmonary edema)
10. URGENT MANAGEMENT
Some patients’ clinical condition may improve quickly with urgent
rate control while others need to have sinus rhythm restored
immediately.
Clinical judgement is needed to determine whether rate control
should be tried or whether to proceed directly to cardioversion
Of equal importance is recognition that cardioversion in patients who
have been in AF for 48 hours or longer, or of unknown duration, is
associated with an increased risk of stroke and should not be
performed in the absence of performing transesophageal
echocardiography to screen for thrombus or at least three weeks of
anticoagulation, unless the patient is critically ill and no alternatives
to cardioversion are available
11. In a patient with any of these indications for urgent cardioversion,
and no alternative treatment options and/or failure to respond to rate
control, the need for restoration of normal sinus rhythm takes
precedence over the need for protection from thromboembolic risk.
(benefit outweighs the risk (5-7%))
Intravenous anticoagulation with heparin or administration of a newer
oral anticoagulant (eg, dabigatran, apixaban, or rivaroxaban) should
be started, but it should not cause a delay in emergent cardioversion.
13. STABLE PATIENT
•Perform a complete history and physical examination, including an attempt
to obtain old records that might contain information about prior
supraventricular arrhythmias. The history is particularly helpful in the
decision to pursue a rate or a rhythm control strategy
•Risk factors for AF, as well as disease associations, may be identified. Old
records should be searched for evidence of a prior episode of AF or other
atrial tachyarrhythmias.
•Identify associated comorbidities that may place a patient at risk of stroke or
bleeding.
•A 12-lead electrocardiogram (ECG) should be performed to verify the
diagnosis of AF and assure that ongoing ischemia is not present on the ECG.
Old records should be searched for evidence of a prior episode of AF or
other atrial tachyarrhythmias.
•Order laboratory tests including electrolytes, cardiac markers
14. STABLE PATIENT
●Start a ventricular rate slowing drug for patients in whom this is
indicated.
● For patients with a rapid ventricular response, who manifest
symptoms or signs of hypoperfusion, rate control (or cardioversion)
may be needed urgently.
●Determine the need for anticoagulant therapy based on an
assessment of stroke and bleeding risks.
●Discuss with the patient the cause (if known), prognosis, and natural
history of AF.
●Consult a cardiologist or electrophysiologist (if needed).
●Schedule follow-up.
15. WORKUP
Laboratory Tests
• Thyroid-stimulating hormone, free T 4
• Serum electrolytes
• Toxicity screen
• CBC count (looking for anemia, infection)
• Cardiac enzymes—CK and/or troponin level (to investigate
cardiomyopathies or myocarditis and myocardial infarction)
• BNP (to evaluate for CHF)
• D-dimer/CT scan of chest PE protocol (if the patient has risk factors to
merit a pulmonary embolism workup)
16. RATE VS RHYTHM CONTROL
Rate Control vs Rhythm Control
**no clear survival benefit in rate vs rhythm control**
17. RATE CONTROL
For most patients with new onset atrial fibrillation (AF) and who are in
AF at the time of presentation, rate control will precede any attempt
to restore sinus rhythm; the principal exception is patients who are
hemodynamically unstable
In patients with mild to moderate symptoms, slowing the rate often
results in significant improvement or even resolution of symptoms.
18. RATE CONTROL
We believe that attempting to get the rate below 85 beats per minute
at rest is reasonable in symptomatic patients.
For patients who continue with unacceptable symptoms at this goal,
an attempt should be made to see if a lower rate goal lessens
symptoms.
For asymptomatic patients with permanent AF, a more lenient rate
control goal of <110 beats/min may be reasonable
19. RATE CONTROL
Agents:
Beta Blocker: Metoprolol and Propranolol,bisoprolol (ICU=esmolol gtt)
Non-dihydropyridine CA blockers: verapamil & Diltiazem (ICU=diltiazem
gtt)
Digoxin
20. DRUG SELECTION
The drug selected and the route of administration (oral versus
intravenous) are dictated by the clinical presentation:
•Beta blockers or verapamil or diltiazem are the preferred to digoxin in
the absence of heart failure (HF).
•Intravenous or oral amiodarone may help control rate when the other
drugs are ineffective or cannot be given.
•Digoxin is the preferred drug only in patients with AF due to HF.
Digoxin can also be used in patients who cannot take or who respond
inadequately to beta blockers or calcium channel blockers. The effect
of digoxin is additive to both of these drugs.
21. DRUG SELECTION
The choice among a beta blocker, diltiazem, and verapamil is frequently
based upon physician and patient preference, although it may be influenced
by other medical problems that are present.
As an example, beta blockers are particularly useful when the ventricular
response increases to inappropriately high rates during exercise, after an
acute myocardial infarction, and when exercise-induced angina pectoris is
also present.
Intravenous beta blockade is more effective than intravenous calcium
channel blockade for rate control , especially after cardiac surgery.
If there is a question about tolerance of the beta blocker, a drug with a short
half-life would be recommended.
On the other hand, a calcium channel blocker is preferred in patients with
chronic obstructive pulmonary disease and asthma.
25. RESTORATION OF SINUS RHYTHM
• In patients with recent onset atrial fibrillation (AF), who are
hemodynamically stable (with only mild to moderate symptoms) and
whose rate has been controlled (as discussed above), a decision
needs to be made regarding the restoration of sinus rhythm.
•We believe that most patients with symptomatic new onset AF and
most patients with apparently asymptomatic AF should have at least
one attempt at cardioversion (either electrical or chemical) to sinus
rhythm.
26. RESTORATION OF SINUS RHYTHM
Circumstances in which it is reasonable to not attempt cardioversion
in a patient with new onset AF include:
●Patients who are completely asymptomatic, particularly those who
are very elderly (>80 years) with multiple comorbidities, where risks
of undergoing cardioversionand/or pharmacologic rhythm control
may outweigh the benefits of restoring sinus rhythm.
27. REASONS TO NOT CARDIOVERT
●Low likelihood of successful cardioversion or maintenance of SR
after cardioversion:
•AF has been present continuously for more than one year
•The left atrium is markedly enlarged (atrial dimension >5.0 cm;
atrial volume >40 mL/m2)
•Patients who had recurrence while taking adequate doses of
appropriate antiarrhythmic drug therapy and have recently undergone
cardioversion. Drug refractory patients may have successful
conversion to SR but are less likely to maintain SR long term.
•Cardioversion with long-term maintenance of SR is likely to be
unsuccessful if the underlying cause (eg, thyrotoxicosis, pericarditis,
and mitral valve disease) for the AF has not been corrected prior to
cardioversion.
28. TIMING
•There is a low risk of systemic embolization if the duration of the
arrhythmia is 24 to 48 hours or less and there are no cardiac
abnormalities (particularly mitral valve disease or significant left
ventricular enlargement due to a cardiomyopathy) on transthoracic
echocardiography.
• Most patients with new onset AF of longer than 48 hours duration
should have cardioversion postponed until:
Three weeks of anticoagulation has been achieved
Or
A transesophageal has been performed and shows no left atrial
appendage clots
29. ELECTRICAL VERSUS
PHARMACOLOGIC
CARDIOVERSION
1. The choice of electrical or pharmacologic cardioversion depends
upon the comfort of the clinician to use one or the other approach.
2. For first episodes, electrical cardioversion is preferred.
3. In some patients, antiarrhythmic drugs are administered prior to
cardioversion to increase the chance of successful reversion and to
prevent early, intermediate, and late recurrence.
4. For patients with paroxysmal episodes of AF, drug therapy is
preferred if they will have sinus rhythm maintained with long-term
antiarrhythmic drug therapy, and as patients with paroxysmal AF
will likely convert anyway with or without electrical cardioversion.
30. ELECTRICAL VERSUS
PHARMACOLOGIC
CARDIOVERSION
• In the acute setting, pharmacologic cardioversion (e.g., ibutilide,
dofetilide) is less commonly used than electrical cardioversion.
•A major disadvantage with pharmacologic cardioversion is the risk of
development of ventricular tachycardia and other serious
arrhythmias, especially due to acute prolongation of the QT interval.
31. ELECTRICAL CARDIOVERSION
●Synchronized DC cardioversion should be performed while the
patient is under the influence of procedural sedation and is having
blood pressure, heart rate, oxygen saturation, and CO2 capnography
monitored.
Generally, cardioversion should be done in a situation where airway
equipment and airway expertise are present.
32. PHARMACOLOGIC CARDIOVERSION
As mentioned before, some patients have antiarrhythmic drugs
started before direct current (DC) cardioversion
Rarely, an attempt at cardioversion with an antiarrhythmic drug alone
can be appropriate, such as those for whom the risk of anesthesia is
high.
Flecainide, propafenone, ibutilide, dofetilide, and, to a lesser
degree, amiodarone all have efficacy for pharmacologic conversion of
atrial fibrillation (AF).
Of these, we prefer flecainide or propafenone unless the duration of
AF is greater than seven days, in which case dofetilide, or, to a lesser
degree, amiodarone or ibutilide have some role for medical
conversion.
33. PHARMACOLOGIC CARDIOVERSION
Flecainide — Flecainide is a very effective antiarrhythmic drug for the
pharmacologic conversion of a patient with AF of short (<24 hours)).
Flecainide should not be used in patients with structural heart
disease, particularly those with left ventricular systolic dysfunction
and in those with coronary artery disease.
34. PHARMACOLOGIC CARDIOVERSION
Propafenone — Propafenone is significantly more effective in
paroxysmal as opposed to persistent AF, with rates likely
approaching those seen with flecainide
As with flecainide, we do not suggest using propafenone in patients
with structural heart disease, particularly those with left ventricular
systolic dysfunction and those with coronary artery disease.
35. PHARMACOLOGIC CARDIOVERSION
Amiodarone — Cardioversion with either intravenous or
oral amiodarone is not particularly effective and occurs several hours
later than with flecainide, propafenone,ibutilide, and vernakalant
Intravenous amiodarone may be more effective in converting AF after
it has been given for hours and days.
Oral amiodarone requires long-term loading and is effective in
converting about 25 percent of patients with persistent AF to sinus
rhythm after six weeks of loading.
Thus, we do not recommend it solely for the purpose of
cardioversion.
It is not approved by the United States Food and Drug Administration
for the treatment of AF.
36. PHARMACOLOGIC CARDIOVERSION
However, amiodarone may occasionally have value before
cardioversion in patients who will receive the drug long term for
maintenance and may be considered as adjunctive therapy to increase
the likelihood of successful cardioversion in patients who are known
to be refractory to electrical cardioversion or in those in whom there
is a concern about early relapse.
37. PHARMACOLOGIC CARDIOVERSION
Vernakalant — Vernakalant is a relatively new antiarrhythmic drug
that has not been as extensively studied as all of the above agents.
It is available in Europe in intravenous forms for the rapid conversion
(50 percent conversion within 10 minutes) of recent-onset AF (≤7
days duration for patients not undergoing surgery, and ≤3 days
duration for post-cardiac surgery patients) to sinus rhythm
42. ANTICOAGULATION
Most patients with new onset atrial fibrillation (AF) will revert to sinus
rhythm spontaneously or undergo an attempt at cardioversion.
●For patients with AF of more than 48 hours (or unknown) duration,
we recommend at least three weeks of oral anticoagulation prior to
cardioversion, and four weeks or more of anticoagulation following
cardioversion.
For patients in whom more urgent restoration of sinus rhythm is
desirable for a variety of reasons (including hemodynamic
compromised symptoms, difficult rate control, or patient
convenience), an alternative strategy is to perform a transesophageal
echocardiogram prior to cardioversion to rule out left atrial thrombi
and proceed to cardioversion if no thrombi are detected
(anticoagulate for at least four weeks after cardioversion).
43. ANTICOAGULATION
Anticoagulant therapy should be continued for at least 1 mo after
cardioversion to minimize the incidence of adverse thromboembolic
events. It can be stopped after 1 mo as long as AF has not recurred.
(independament du CHADS score)
44. ANTICOAGULATION
●For patients with AF of less than 48 hours duration, our reviewers
have differing approaches.
Some start unfractionated heparin, low molecular weight heparin, or a
newer oral anticoagulant prior to cardioversion in all patients, while
some proceed without anticoagulation in patients with AF of very
short duration who have a low stroke risk profile.
●For patients with a first episode of AF, our experts have differing
approaches to the decision regarding long-term anticoagulation.
Most anticoagulate based on risk, as determined by the CHA2DS2-
VASc score
However, some will not anticoagulate after a first episode, particularly
if a reversible cause has been identified.
47. RATE VS RHYTHM
Per the AFFIRM and RACE trials, either rate control or rhythm control
strategies show no difference in composite cardiovascular end points
of death, CHF, bleeding, drug side effects, or thromboembolism.
Both approaches have similar outcomes as long as appropriate
anticoagulation is maintained based on the individual’s stroke risk.
48. RATE CONTROL
For patients without symptomatic AF, rate-control strategy with
calcium channel blockers, beta-blockers, or digoxin is a reasonable
option.
RACE 2 trial indicates that a lenient rate control strategy, with a target
resting heart rate of <110 beats/min is non inferior for a composite
primary end point that included CV death, heart-failure
hospitalization, stroke, and other major events over a median 3-yr
follow-up as compared to a strict control strategy, with a target
resting heart rate of <80 beats/min and an exercise heart rate of
<110 beats/min.
49. RHYTHM
• In patients with symptomatic AF, younger patients, or those with
difficult to control heart rate, attempt should be made to maintain
sinus rhythm with antiarrhythmic agents.
Options of antiarrhythmic agents include amiodarone, dronedarone,
(paroxysmal atrial fibrillation only without heart failure), dofetilide,
flecainide, propafenone (contraindicated with structural heart
disease), procainamide, or sotalol.
Use of dronedarone should be avoided in patients with persistent
and/or permanent atrial fibrillation due to worsened cardiovascular
outcomes, especially in those with concomitant symptomatic heart
failure
50.
51.
52.
53. ANTICOAGULATION
The decision whether to pursue long-term anticoagulation must be
made in light of the patient’s risk for a cardioembolic event versus
risk for a bleeding event. The CHA2DS2-VASc has largely superseded
the CHADS2 scoring system
54. CHA2DS2-VASC
C = congestive heart failure;
H = hypertension;
A = age (>75 years is 2 points);
D= diabetes;
S= stroke, transient ischemic attack, or thromboembolic disease (2 points);
V = vascular disease,
A = age 65-74 years; and
Sc = sex category, with females getting 1 extra point).
Patients with a CHA2DS2-VASc score of 0 are considered low risk, 1 to 2 are
considered moderate risk, and >2 are considered high risk and would
benefit from long-term anticoagulation (e.g., warfarin).
55. ANTICOAGULATION STRATEGY
Anticoagulation with warfarin is generally not recommended in
patients with CHADS-VASc score of >1 (other than for female), there
is mounting evidence of benefit for anticoagulation.
Increasing amounts of evidence now show that aspirin likely does not
protect a person from stroke in AF and has recently been dropped
from the European Atrial Fibrillation guidelines.
Target INR for patients with a CHADS-VASc score of >2 is 2 to 3 and
should be diligently monitored to avoid risk of stroke versus
bleeding.
Patients with hypertrophic cardiomyopathy or thyrotoxicosis with AF
also have a high risk of stroke and should be anticoagulated
irrespective of their CHADS-VASc score.
56. COUMADIN
For CHAD2S2-VASc- score 2 or greater
Goal INR= 2 to 3
Must monitor INRs regularly
Can be dangerous if fall risk or bleeding risk high
57. DABIGATRAN
Direct Thrombin Inhibitor
RE-LY Trial showed superior to warfarin in preventing ischemic and
hemorrhagic CVAs with reduced risk of life threatening bleeding but
higher risk of GI bleeds
No lab monitoring*
No reversal agent available for major bleeding events
58. RIVAROXABAN
Oral factor Xa inhibitor
Seems to be equivalent in efficacy to warfarin for CVA prevention and
no difference in major bleeding events
Demonstrates a reduction in intracranial hemorrhage
Note: risk of thrombotic events increased for 28 days after stopping
drug so may need to bridge with another anticoagulant during this
time.
59. CASE VIGNETTE
This is a 65 y/o M who presents to the ED with dizziness, shortness
of breath, and palpitations which began approximately two hours ago
when he was playing catch with his grandson. No syncope or chest
pain.
On exam: He is afebrile with a BP=110/55, HR=110-162 bpm, and
respiratory rate of 25. A&Ox4 w/ NAD. Cardiac exam reveals
tachycardia with an irregularly irregular rhythm.
How would you approach the initial management of this patient?
Editor's Notes
Here is an example/review of what an EKG may look like in the previous patient with afib. Atrial activity is rapid (>320 bpm) without any organized activity, and of various amplitudes. No discrete P waves are seen in this image. There is also irregularly irregular ventricular response which shows up as variable R-R intervals. The Ventricular response is usually 130-200.
-Urgent cardioversion W/ defibrillator: if hemodynamic instability, hypotension, angina, heart failure
-if cardioverting, ensure R-wave synchronization w electrical cardioversion to prevent “R-on-T” shock which can induce Vfib
-there is also a role in the management of recent or new onset afib for elective cardioverting when the patient is hemodynamically stable and one wishes to try to bring them out of the arrhythmia however the details of that are beyond the scope of this talk.
IMPORTANT:Remember to remind people that there is no clear mortality or stroke reduction benefit in rate vs rhythm control. This could be because of premature d/c of anticoagulation and antiarrhythmic drugs in those who underwent rhythm control.
-asymptomatic patients with HR goal <110 can be managed with rate control if EF>40%
-in patients with symptoms despite rate control can consider rhythm control
Here are some choices of medications for rate control.
-remind students that not all Ca channel blockers can be used (i.e amlodipine would not be a good choice)
-also on this slide is the goal HRs for rate control and meds should be titrated to reach these goals but must also watch blood pressure because all these meds can cause some hypotension to varying degrees.
Remind people that can reverse coumadin if need be with vitamin K and FFP
* No lab monitoring good in the sense that patients do not have to come regularly to get checked but bad in the sense that there is no way to monitor the true extent of the anticoagulation
Answer: Although this patient is symptomatic they are hemodynamically stable and mentating well. There appears to be no role for urgent cardioverting (such as unresponsive, change in mental status, hypotension) so the patient can be managed medically. We will now review how to manage this kind of patient.