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Atrial fibrilation
- 1. (Adapted from the2006 ACC/AHA/ESC Guideline and the 2011 ACCF/AHA/HRS Focused Updates) Rania I.Elashkar Heart Hospital 10.March.2014 Rate and Rhythm control for Atrial Fibrillation
- 2. Objectives After this presentation,we shall learn: • Healthy heart • What is AFib; • How to detect AFib using ECG ? • What causes Afib • Different types of Afib • control of venticular rate in patients with Afib. • rhythm control in AFib
- 3. An Overview OnAtrial Fibrillation
- 4. Prevalence of diagnosedAFib by age and Gender
- 5.
- 6.
- 7. AF and heartfailure (HF) LA indicates left atrial; MR, mitral regurgitation; and TR, tricuspid regurgitation.
- 8.
- 9. Rate Control: Advantages&Limitations
- 10. Rhythm Control: Advantages& Limitations
- 11. no mortality benefitto rhythm control compared to rate control
- 12. Candidates for RateControl
- 13.
- 14. Rate Control: Beta- Blockers • Recommended for rate control in most patient with AFib (class I) • Most appear to have similar efficacy. • Should be administered at frequency that prevent periods of breakthrough tachycardia. • Preferred for patient with LV dysfunction. • Beta blockers should be used cautiously in patients with HF(reduce heart rate &cardiac contractility)
- 15. Rate Control: CalciumChannel Blockers • Recommended for rate control in most patient with AFib (class I) • Used when Beta –Blockers are contraindicated for obstructive airway disease patients. • Caution in patient with LV dysfunction • calcium channel antagonists should be used cautiously in patients with HF(reduced heart rate &contractility)
- 16. Rate Control :Digoxin • Recommended for rate control in AFib patient with LV dysfunction(class I). • Combination with Beta – Blockers or Calcium Channel Blockers (class IIa). • Reduce Ventricular Rate by increasing vagal tone to the AV node(not useful in High adrenergic tone patients). • Iv digoxin is contraindicated in WPW syndrome (ventricular preexcitation).
- 17.
- 18. Candidates for Rhythmcontrol
- 19. Rhythm control strategy •Restoration of Sinus Rhythm e.g.(IV ibutilide, flecainide and propafenone). • Maintenance of Sinus Rhythm Antiarrhythmic drug choice is based on side effect profiles and the presence or absence Of structural heart disease, HF, and hypertension • Specific Antiarrhythmic Drugs Sotalol prevent Afib. Dofetilide used to maintain SR but cause proarrhythmia
- 20. Rhythm Control :Pill in the Pocket • Patients use self administered oral dose of rhythm control drug when AFib symptoms reappear. • propafenone and flecainide has been studied for the use “pill in the pocket” strategy. • should not be used in patients with ischemic heart disease or LV dysfunction due to the high risk of proarrhythmia
- 21.
- 22. Rhythm control :Amiodarone • Most effective antiarrhythmic drug. • Initial choice in Afib patients with LVH,HF OR CAD due to low risk proarrhythmia. • Patients should be monitored at least annually for thyroid, hepatic, and pulmonary toxicity • Low-dose amiodarone (≤ 200 mg daily) is associated with fewer side effects than higher-dose regimens
- 23. Rhythm control • Dronedaronehas similar antiarrhythmic effects to amiodarone but less frequent complication associated with amiodarone.
- 24.
- 25. Antiarrhythmic drugs vs.ablation in HD
- 26. Conclusion •Elderly & asymptomaticbenefit the most from rate control with out attempt to restore NSR in Afib. •If rate control offers inadequate symptomatic relief, restoration of NSR may become a long term goal. •Prevent thromboembolism in all Afib except lone Afib or contraindicated.
- 27. Case study 1 74years old Female BP=120/70 mm Hg irregular pulse =120 bpm at rest increasing fatigue over the prior 3 months. history well-controlled, systolic hypertension & LV dysfunction No heart failure, NO myocardial ischemia Lab complete blood count, electrolytes, HbA1c and liver function Normal limit. Management • rate control was started to relief symptoms (metoprolol xl) but was limited by hypotension. • Direct cardioversion to restore NSR ,TEE confirmed no thrombus. • Antiarrhythmic added to maintain sinus rhythm(amiodarone). • Chronic anticoagulation(female,75,hy pertensive)use warfarin target 2-3
- 28. References •Pharmacotherapy: A pathophysiologicapproach. Edited by J. T. DiPiro, R. L. Talbert, P. E. Hayes, G. C. Yee, and L. M. Posey. Elsevier Science •Wann, L. S., Curtis, A. B., January, C. T., Ellenbogen, K. A., Lowe, J. E., Estes, N. M., ... & Kay, G. N. (2011). 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline) A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 57(2), 223-242. •Bradley P. Knight, MD, FHRS (2013)The Practical Rate and Rhythm Management for the Cardiologist Pocket Guide was adapted from the 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Editor's Notes
- #6 Longstanding persistent: Continuous AF of >1 year duration.
- #7 ATRIAL BEAT =400 -600 bpm Irregular Venticular pulse =120-180 bpm
- #9 Underlying disease (secondaryAfib ) is not the primary problem ,and treatment of underlying disorder usually terminates the arrhythmia Examples:Acute myocardial infarction(MI),Cardiac surgery,Pericarditis,myocarditis. Hyperthyroidism,Acute pulmonary disease. Conversely, when Afib occurs in the course of a concurrent disorder like well –controlled hypothyroidism the general principles for management of the arrhythmia apply
- #10 A hemodynamically unstable patient is one whose blood pressure is so low that his body tissues are not being provided with an adequate supply of blood.
- #11 Some antiarrhythmic drugs that are used to maintain sinus rhythm, such as sotalol, dronedarone, and amiodarone, also provide some control of the ventricular response when patients are in AF.
- #12 AFFIRM,RACE AND AF-CHF trials have proved RACE (RAte Control versus Electrical cardioversion for persistent atrial fibrillation) was a prospective randomized trial comparing both strategies. The primary end point was a composite of death from cardiovascular causes, heart failure, thromboembolic complications, bleeding, pacemaker implants and severe adverse effects of drugs. After a mean follow-up of 2.3 years, the primary end point occurred in 44 of the 256 rate control patients (17.2%) and 60 of the 266 rhythm control patients (22.6%). Other trials as the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management), PIAF (Pharmacological Intervention in Atrial Fibrillation) and STAF (Strategies of Treatment of Atrial Fibrillation) also found that rate control was not inferior to rhythm control in terms of morbidity, mortality and quality of life. These four randomized trials demonstrated that a rate control strategy is an acceptable alternative to rhythm control in patients with recurrent atrial fibrillation. For those with severely symptomatic atrial fibrillation, continued rhythm control is unavoidable. For these patients, safer and more effective methods of maintaining sinus rhythm are needed to reduce morbidity related to palpitations and atrial fibrillation-induced heart failure.Furthermore, the randomized studies showed that rhythm control therapy does not prevent stroke. It was observed from RACE that 21 of the 35 thromboembolic complications occurred under rhythm control, the majority while receiving inadequate anticoagulation therapy. Also in AFFIRM, with patients with one or more stroke risk factors, more strokes were present under rhythm control. Therefore, one of the main lesson learned from the randomized studies is that anticoagulation must be continued if stroke risk factors are present even if patients maintain sinus rhythm.
- #13 LA dimensions Normal Mildly dilated Moderately dilated Severely dilated Diameter (mm) 28-40 41-46 47-52 >52Major axis (mm) 41-61 62-67 68-76 >77 Area (cm2) <20 20-30 30-40 >40 Volume (ml) 22-58 59-68 69-78 >79
- #14 Rate control. COPD = chronic obstructive pulmonary disease. *Small doses of β1-selective blockers may be used in COPD if rate control is not adequate with non-dihydropyridine calcium channel antagonists and digoxin. Amiodarone is also used for rate control in patients who do not respond to glycosides, β-blockers or non-dihydropyridine calcium antagonists. Dronedarone may also be used for rate control in patient with recurrent episodes of atrial fibrillation.
- #15 Beta Blockers Atenolol PO: 25-100mg daily Bisoprolol PO: 2.5mg daily; can be titrated to 20mg daily Carvedilol PO: 3.125-25mg every 12 hrs (up to 50mg every 12 hrs for patients > 85kg), may use carvedilol sustained release 10-80mg daily Esmolol IV: 500 mcg/kg over 1 min, then 50-200 mcg/kg/min Metoprolol IV: 2.5-5mg bolus over 2 min (up to 3 doses) PO: 25-100mg bid, may use metoprolol succinate ER 25-200mg daily
- #16 Calcium Channel Blockers Diltiazem IV: 0.25mg/kg (avg 20mg) over 2 min (2nd bolus can be given if HR >100bpm), then 5-15mg/hr, PO: 120-360mg daily (slow release preferred) Verapamil IV: 0.075-0.15mg/kg over 2 min ,PO: 120-360mg daily (slow release preferred)
- #17 . Digoxin IV: 0.25mg q2hrs (up to 1.5mg), then 0.125-0.375mg daily PO: 0.125-0.375mg daily Digoxin provides relatively poor rate control during exertion and should be reserved for patients who are sedentary or those with systolic HF. • Digoxin does not convert AF to SR and may perpetuate AF. IV digoxin and nondihydropyridine calcium channel antagonists are contraindicated in patients with ventricular preexcitation during AF (WPW syndrome) because they may accelerate the ventricular response and precipitate VF. Wolff–Parkinson–White syndrome (WPW) is one of several disorders of the conduction system of the heart that are commonly referred to as pre-excitation syndromes. WPW is caused by the presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles. Electrical signals travelling down this abnormal pathway (known as the bundle of Kent) may stimulate the ventricles to contract prematurely, resulting in a unique type of supraventricular tachycardia referred to as an atrioventricular reciprocating tachycardia.
- #18 Control of the ventricular rate during AF is important both at rest and with exertion. • Criteria for adequate rate control vary: – For the AFFIRM trial, adequate control was defined as an average HR<80 bpm at rest and either an average rate<100 bpm during Holter monitoring with no rate above 100% of the maximum age-adjusted predicted exercise HR, or a maximum HR of 110 bpm during a 6-min walk test.12 – In the RACE II trial, lenient HR control (target <110 bpm) was noninferior to stric HR control (resting rate<80 bpm and rate during moderate exercise <110 bpm).13
- #19 Case study 1
- #20 Sotalol is a nonselective beta-blocking drug with class III antiarrhythmic activity that prolongs repolarization. It is not effective for conversion of AF to sinus rhythm, but may be used to prevent AF. Sotalol should be avoided in patients with asthma, HF, renal insufficiency, or QT interval prolongation and should be used with caution in those at risk for torsades de pointes (e.g. female, age > 65 yr, taking diuretics). • Dofetilide is class III drug that prolongs repolarization by blocking the rapid component of the delayed rectifier potassium current.effective in maintaining sinus rhythm. To reduce the risk of early torsades de pointes, dofetilide must be initiated in the hospital at a dose titrated to renal function and the QT interval. Dofetilide is safe to use in patients with coronary artery disease or CHF. The FDA mandates prescriber registration and inpatient loading for initiation of this medication due to its proarrhythmic potential.
- #21 Generally, a beta blocker or a calcium channel blocker should be taken an hour prior to taking the antiarrhythmic drug when trying to convert AF to SR. Flecainide and propafenone are class IC drugs that delay conduction by blocking sodium channels. Propafenone also exerts mild beta-blocking effects, Class IC drugs can slow the atrial rhythm during AF resulting in acceleration of the ventricular response. Therefore, these agents should be combined with AV nodal blocking drugs to maintain rate control when AF recurs.
- #22 Vaughan Williams Class I Flecainide PO: 50-150mg every 12 hrs Propafenone PO: 150-300mg every 8 hrs, or sustained release 225-425mg every 12 hrs Vaughan Williams Class III Amiodarone IV: 150mg over 10 min, then 0.5-1mg/min PO: 200mg TID x 2 wks, 200mg BID x 2 wks, then 200mg daily. Take with meals. Dofetilide PO: 125-500mcg every 12 hrs, based on renal function and QTc; must be initiated in the hospital Dronedarone PO: 400mg twice daily with meals Ibutilide IV: ≥ 60kg – 1mg over 10 min; <60kg – 0.01mg/kg over 10 min while observing for QTc prolongation and ventricular proarrhythmia. Dose can be repeated after 10 min but the risk of proarrhythmia increases. Pre-treatment with MgSO4 1-2 gm IV may reduce the risk of TdeP. Sotalol PO: 80mg BID, to a maximum of 240-320mg/day, based on renal function and QTc
- #23 Amiodarone :most effective antiarrhythmic drug, but is associated with relatively high toxicity, making it a second-line or last-resort agent in many cases. Amiodarone is an appropriate initial choice in patients with LVH, HF, or CAD, because it is associated with a low risk of proarrhythmia. Outpatient initiation may be considered in the absence of other risk factors for torsades de pointes and sinus or AV node dysfunction. Patients taking amiodarone should be monitored at least annually for thyroid, hepatic, and pulmonary toxicity. Low-dose amiodarone (≤ 200 mg daily) is associated with fewer side effects than higher-dose regimens. Amiodarone side effects :Very Rapid Heartbeat - Torsades de Pointes, Sudden Rapid Heartbeat-Paroxysmal Ventricular Tachycardia, Ventricular Fibrillation, Sinus Bradycardia, Abnormal Heart Rhythm, Chronic Heart Failure,over or under active thyroid, Abnormal Liver Function Tests
- #24 Dronedarone is an analog of amiodarone with far lower risk of organ toxicity. Outpatient initiation may be considered in the absence of other risk factors for torsades de pointes, and sinus or AV node dysfunction. Dronedarone is indicated to reduce the risk Of cardiovascular hospitalization in patients with paroxysmal or persistent AF/AFL, with a recent episode of AF/AFL and associated cardiovascular risk factors, who are in sinus rhythm or who will be cardioverted. • Dronedarone is contraindicated in patients with decompensated congestive heart failure. It should be avoided in patients with advanced CHF. It is also contraindicated in patients with permanent AF (patients in whom sinus rhythm will not or cannot be restored) and for the sole purpose of rate control. • There is a very small risk of liver toxicity with dronedarone and, therefore, liver function testing is recommended after drug initiation
- #25 Summary of randomized control trials comparing catheter ablation versus antiarrhythmic therapy. Three studies shown enrolled patients with paroxysmal atrial fibrillation (AF), 2 studies enrolled patients with persistent AF, and a mixed population was enrolled in 3 studies. AAD indicates antiarrhythmic drugs.
- #26 When a rapid ventricular response does not respond promptly to pharmacological measures for AF patients with ongoing myocardial ischemia, symptomatic hypotension, angina, or HF, immediate CV is recommended( heamodynamicly unstable patients) Electrical CV is contraindicated in patients with digitalis toxicity or hypokalemia
- #27 Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF regardless of whether a rhythm or rate control strategy
- #28 Medications The primary goals of AF management include symptom relief and thromboembolic prophylaxis. The acute management of this patient should be centered first on symptom relief in the form of improved rate control to reduce the resting heart rate to less than 110 bpm. Digoxin is less effective for rate control than beta-blockers or nondihydropyridine calcium-channel blockers (e.g., verapamil or diltiazem), but it can be considered if blood pressure is low. In this patient case, the presence of worsened left ventricular function is likely the result of tachycardia and necessitates aggressive rate control in the short term. The condition is a reasonable justification to attempt restoration of sinus rhythm with the hope that left ventricular function will return to normal. Restoring sinus rhythm by cardioversion should be preceded by measures to reduce the risk of pericardioversion stroke, including either a transesophageal echocardiogram to exclude left atrial appendage clot or a minimum of 3 consecutive weeks of dabigatran or 3 consecutive weeks with an INR of ³ 2, if using warfarin. . In this woman with left ventricular dysfunction without congestive heart failure, potential drug choices include dronedarone, dofetilide, sotalol or amiodarone . Amiodarone was chosen and initiated at a dose of 200 mg three times a day for 1 month with reduction to 200 mg a day after 1 month. Liver function tests, thyroid function tests and pulmonary function tests and a baseline chest x-ray were obtained at the time of amidoarone initiation. Left ventricular function returned to the baseline of 40% after 6 weeks of amiodarone. Given the high likelihood of recurrent AF and the patient’s presentation with tachycardia-mediated myopathy, her low, 200 mg/day dose of amiodarone was continued. Ultimately, if amiodarone proves unsuccessful or not tolerated, referral for catheter-based pulmonary vein isolation is an option. Anticoagulation Recommendations for chronic anticoagulation in patients with AF are determined by clinical risk factors such as history of congestive heart failure, hypertension, age older than 64 or 75, diabetes mellitus or past stroke or TIA (Table 1). In addition, female sex and vascular disease also appear to increase the risk of stroke and have been added to a new risk stratification scheme called CHA2DS2-VASc. Regardless of the scheme, associated clinical characteristics rather than the pattern or frequency of AF determines stroke risk. Current Recommendations for Thromboembolic Prophylaxis Based on Risk Factors for Stroke In this patient’s case the risk factors for stroke, including sex, age and hypertension, together mandate chronic anticoagulation regardless of the decision to maintain sinus rhythm or control rate (Table 1). The choices for anticoagulation include warfarin with a target INR of ³ 2 or dabigatran 150 mg, provided that the creatinine clearance is greater than 30 ml/min. If the creatinine clearance is between 15 and 30 ml/min, a dabigatran dose of 75 mg twice a day is recommended. Continuing aspirin along with either warfarin or dabigatran is not necessary. Other Options In this case dabigatran was initiated. Rate control was attempted with an increased dose of metoprolol XL but was limited by hypotension. As a consequence, a TEE was performed to exclude an existing thrombus and allow cardioversion. The procedure demonstrated a left atrial appendage (LAA) velocity of > 20 cm/sec with faint contrast in the left atrium. This preserved LAA velocity and the absence of dense spontaneous left atrial contrast allowed DC cardioversion to be performed safely. In addition, an antiarrhythmic drug was prescribed to increase likelihood of maintenance of sinus rhythm prior to a reassessment for recovery of ventricular function.