This document summarizes guidelines for rate and rhythm control for atrial fibrillation. It discusses using medications like beta blockers, calcium channel blockers, and digoxin for rate control. For rhythm control, electrical cardioversion or antiarrhythmic drugs may be used to restore normal sinus rhythm, with amiodarone being preferred for patients with heart failure or coronary artery disease due to its lower risk of side effects. The document also discusses when rate control versus rhythm control strategies are preferred based on patient characteristics and presents a case study on managing a patient with atrial fibrillation.
A Case study of patients Suffering From Atrial fibrillation and Hypothyroidism Disease.with Dugrs Fellow up 5 days with laboratory results Included of patient..
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
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.
A Case study of patients Suffering From Atrial fibrillation and Hypothyroidism Disease.with Dugrs Fellow up 5 days with laboratory results Included of patient..
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
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.
The following powerpoint presentation is about the current AF guidelines, prepared by Dr Jawad Siraj, who is a final year resident as Cardiology Unit, PGMI, LRH, Peshawar
Atrial fibrillation (A-tre-al fi-bri-LA-shun), or AF, is the most common type of arrhythmia (ah-RITH-me-ah). An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.
AF occurs if rapid, disorganized electrical signals cause the heart's two upper chambers—called the atria (AY-tree-uh)—to fibrillate. The term "fibrillate" means to contract very fast and irregularly.
The following powerpoint presentation is about the current AF guidelines, prepared by Dr Jawad Siraj, who is a final year resident as Cardiology Unit, PGMI, LRH, Peshawar
Atrial fibrillation (A-tre-al fi-bri-LA-shun), or AF, is the most common type of arrhythmia (ah-RITH-me-ah). An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.
AF occurs if rapid, disorganized electrical signals cause the heart's two upper chambers—called the atria (AY-tree-uh)—to fibrillate. The term "fibrillate" means to contract very fast and irregularly.
Acute Decompensated Heart failure (ADHF), Heart failure with preserved ejecti...Sangam H B
Brief pathophysiology and management of ADHF and HFpEF
referred from Harrison's internal medicine, Braunwald's Heart Disease, and online sources like uptodate
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
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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
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
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.
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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!
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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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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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.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Atrial fibrilation
1. (Adapted from the 2006 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
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: Calcium Channel
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).
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
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
• Dronedarone has similar antiarrhythmic
effects to amiodarone but less frequent
complication associated with amiodarone.
26. Conclusion
•Elderly & asymptomatic benefit 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
74 years 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 pathophysiologic approach. 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
Longstanding persistent: Continuous AF
of >1 year duration.
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
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.
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.
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.
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.
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
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)
. 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.
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
Case study 1
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.
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.
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
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
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
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.
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
Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF regardless of whether a rhythm or rate control strategy
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.
