summary slides

1. AF 2018
Zipes
MH-Nikoo

2. epidemiology
• Most common arrhythmia in human
• 4-5 fold increase in stroke
• Double the risk of dementia
• Triple the risk of heart failure
• 40-90 % increased risk of mortality

3. • Age dependent
– Double each decade above 55
– O.1% <55,,,,,,,,,,,,,,,,,9% >80
– Life time risk 25% if reached 40
• Men > women

4. classification
• Paroxysmal:
– Terminate spontaneously or with intervention<7d
• Persistent
– Fail to self-terminate <7d and often require
pharmacological or electrical cardioversion
• Long standing persistent
– Persistent> 12 months
• Permanent AF
– Persistent AF for whom combined decision of patient
and clinician is no rhythm control strategy

5. terminology
• AF episodes should last at least 30 second
• Lone AF
– No structural heart disease

6. pathophysiology
• Trigger and substrate
• Haissaguerre 1988
– focal ecotyp from PV (PV trigger)

7. clinical
• Most common symptom ,,,,,,,,,,,,,, palpitation
• 5-15% drop in cardiac output
• Rapid ventricular response in LVH or coronary
cause flush pulmonary edema angina and
syncope
• Persistent RVR may cause tachy induced CM
which revert if rate or rhythm control

8. • HF and AF Coexist
• One lead to and or participate the other
• Rate or rhythm control restore function and
symptoms

9. • Stroke may be the first presentation
• A third of patient remain asymptomatic and
only discovered in routine exam

10. Key points

11. investigations

12. Cryptogenic Stroke
• ILR detect AF in 12% routine monitor in only
2%

13. ETT
• CAD rarely is cause but should investigate
before using class I anti-arrhythmic drugs
•

14. EPS
• Role is limited and performed before AF
ablation
• in young patients AVNRT or AVRT in 4-10%
identified

15. treatment
• Rate or rhythm
• Medication or Ablation
• Thromboembolic prevention
• Associated conditions

16. Rate Control
• First treatment priority for acute episode if
hemodynamically stable
• AVN blocking if no accessory pathway
• If preexcited AF ibutilide or procainamide

17. Acute anticoagulation
• Necessary before cardioversion if AF longer
than 48 h
• If uncertainty then TEE
• 3-4 week before and 3-4 week after

18. First episode
• Few data
• Cardioversion if duration unknown or less
than 1 years
• Electrical cardioversion has higher success
• Chemical cardioversion:
– Flecainide(in hospital)
– Dofetilide
– Propafenone
– intravenous ibutilide(in hospital)
– Amiodarone(outpatient)

19. Pill in the pocket
• In addition to BB or CCB
• Propafenon or flecainide

20. Rate control
• Target resting rate <80 (if symptomatic)
• Lenient <110 (if asymptomatic, EF>40)

21. Rate control
• BB OR CCB
• Combination: BB + Dig
• Dig should add if single drug is not enough
• BB: high adrenergic and ischemia
• Cardiovert if hemodynamically unstable
• Change to rhythm (PVI)
• AVN ablation + PPM( BiVent. or His) :last

22. Long term management
• Recurrence is common
• Lone AF 60% free over 5 years
• Paroxysmal to persistent or permanent
– 10-20% in 1 years
– 50-77% in 12 years
• Rhythm control strategies slow progression

23. Rhythm control
• No benefit for rate vs. rhythm control
• R or R: individualized with flexibility to cross
over
– >65….........rate
– Ongoing symptoms...................rhythm
– young….................rhythm
– Survive >5 y..............................rhythm

24. Anti-arrhythmic for rhythm
• AF recurrence after cardioversion is high(71-
84%)
• Total elimination is unrealistic and goal is
reduction in frequency and duration
• Safety (little side effects) make the choice
• If SAN or AVN disease pace before AADs

26. Rhythm control
• IA: (Na &K):mostly abandoned except HCM
and hypervagotonia AF
• IC: (Na):
• NL EF. , no CAD , no LVH>1.5
• Daily or pill in the pocket with BB
• Change AF to AFL with WCT(use dependence)
• III: (K) :
• similar efficacy to IC , additional safety
• Start at hospital for torsade prevention

27. Amiodarone
• The most effective drug for prevention
• Multi-channel blocker
• Prolong QT but no Torsade except…...
• Safe in structural heart disease : CAD , CHF
• Multiple toxicity: liver ,thyroid ,lung
• Worsen Bradycardia

28. Dronedarone
• Amiodarone without iodine
• Inferior to Amiodarone for prevention
• Contraindicated in CHF
• Only in normal heart and nonpermanent

29. Long term anticoagulation
• Fivefold increased thrombo-emboli
• Mechanical and hormonal

32. warfarin
• 2<INR<3 reduce stroke 64%
• More efficacious than ASA
• More efficacious than ASA + clopidogrel
•

33. DOAC advantage
• Fixed dosing
• No significant dietary restriction
• Full anticoagulation within 1-4 hours
• more time in therapeutic range

34. DOAC disadvantage
• Lack of adequate testing to indicate patient
compliance
• Lack of reversal agent with factor Xa. inhibitor
• Avoid in creatinine clearance <15
• Avoid in pregnancy
• Avoid in prosthetic valves

35. rivaroxaban
• Inhibitor of factor Xa
• Non inferior to warfarin
• Reduce dose if:
– >80 y
– <60 kg
– Cr>1.5

36. LAA occlusion or removal
• Alternative to anticoagulation
• 90% of observed thrombi in appandage
• Endocardial : Watchman
• Epicardial : LARIAT
• No FDA approval

37. Catheter Ablation for AF
• Symptomatic paroxysmal or persistent AF
refractory or intolerant to at least one class I ,
III anti-arrhythmic
• first line therapy if patient desired

38. ablation
• PV isolation
• Segmental Ostia
• Circumferential(wide area)
• Antral
• To maintain sinus
» Single procedure success 57
» Multiple procedure success 71
» AAD success 52%

39. ablation
• Recurrence almost always means
reconnection
• In persistent AF
– PVI is not enough
– At least Antral Ablation
– CAFÉ , Ganglion, linear , software rotor ablation

40. Ablation complication

41. ablation
• QOL improved(compare to AAD)
• LV dysfunction improved (if done early)
• Not progressed to persistent or permanent
• Symptomatic episodes always reduced