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ATRIAL FIBRILLATION
- 1. Col Bharat Malhotra SeniorAdvisor (Medicine) REFERENCE Harrison’s Principles of internal medicine Harrisons 20th Ed Davidson’s Principles and practice of Medicine (2018) 2020 European Cardiology guidelines on Atrial Fibrillation 2019 American Heart Association Guidelines on AF
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- 4. LEFT ATRIA Normal Electrical Activity •60 – 100 /min • Sinus origin • In Conduction system • Defined Velocity
- 5. BRADYARRTHYMIAS • Sinus Bradycardia •Sick Sinus Syndrome • Sinus node arrest • AV block • First degree • Second degree • Third degree TACHYARRHYTHMIAS • Sinus tachycardia • Atrial flutter • Atrial Fibrillation • Atrial Tachycardia • Focal • Multifocal • AV Junction • AVRT • AVNRT • Ventricular Tachycardia • Ventricular Fibrillation ECTOPICS • Atrial ectopic • Ventricular Ectopic BUNDLE BRANCH BLOCK • Rt BBB • Lt BBB
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- 9. • Supraventricular Tachyarrhythmia •Disorganized, uncoordinated atrial activation • Consequently ineffective atrial contraction • With irregular ventricular rate that is determined by AV conduction
- 10. American Heart AssociationCardiology Guidelines 2019 • Terminates < 7 DAYS • Spontaneous or by Intervention. AF may recur PAROXYSMAL AF • Sustained > 7 DAYS PERSISTENT AF • Sustained > 12 MONTHS LONGLASTING PERSISTENT AF • Joint decision by patient and clinician to cease further attempts to restore sinus rhythm. PERMANENT AF
- 11. REFERENCE Table 16.21 DAVIDSONTextbook of medicine (2018) & European guidelines on A F (2020)
- 12. Yu-ki Iwasaki. Circulation.Atrial Fibrillation Pathophysiology, Volume: 124, Issue: 20, Pages: 2264-2274 • Automaticity • Ectopic focus • Reentry Single circuit reentry Multiple wave reentry Due to genetic variants and signaling changes gradually lead to electrical and structural remodeling
- 13. REFERENCE New England Journalof Medicine JAN 2021
- 14. SVC IVC P Artery PVein Aorta Lungs Lt A Rt A Rt V Lt V
- 15. Asymptomatic Hemodynamically stable Hemodynamically unstable CLINICAL PRSENTATIONS Asymptomatic Hemodynamically Stable Palpitations,Syncope Dyspnea Fatigue, Poor effort tolerance Hemodynamically unstable Palpitations, Syncope Tachycardia, Hypotension Symptoms due to etiology Acute HF, LVF, ACS, Cardiogenic Shock, Valvular Disease Lung pathology, Hyperthyroidism, Others
- 16. Asymptomatic Hemodynamically stable Hemodynamically unstable EXAMINATION Irregularly Irregular Pulse IrregularS1, Apex Pulse Deficit Findings due to possible etiology OUTCOMES • Stroke • Cognitive decline/ Vascular dementia • LV dysfunction/ HF • Sudden Cardiac Death
- 17. Risk of Stroke CHA2DS2-VASc Score Asymptomatic, Mild,Mod, Severe QoL Questionnaires Temporal Pattern • Paroxysmal • Persistent • Long standing persistent • Permanent Comorbidities Comorbidities & Risk factors Assessment Imaging
- 18. The diagnosis ofAF requires rhythm documentation with an (ECG) tracing showing AF • No P Wave • Irregularly Irregular QRS interval • Fibrillatory wave
- 19. Inferior Wall MIwith Atrial Fibrillation with fast ventricular rate
- 20. LVH with AtrialFibrillation with fast ventricular rate
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- 22. ALL AF PATIENTS CHA2DS2-VAScScore AF related symptoms AF burden Comorbidity & risk factors 12 Lead ECG CXR- PA view ECHO T3 T4 TSH CBC Kidney functions, Liver functions Electrolytes, PT INR Cognitive function assessment TREATMENT – AF Rhythm control Rate Control Treat comorbidities Intervention in selected cases by Catheter ablation SELECTED AF PATIENTS Ambulatory ECG Monitoring Transesophageal ECHO CRP, Troponin T, Pro BNP Biomarkers for angina, HF Coronary Angiography Suspected CAD/ACS Brain CT/MRI Suspected stroke CMRI, EP Mapping for LA assessment - Evaluation for catheter ablation
- 23. • CHA2DS2-VASC SCORE,HAS-BLED SCORE • ANTICOAGULANTS Optimized stroke prevention • DC CARDIOVERSION • IV AMIODARONE / other antiarrhythmic agents • CATHETER ABLATION Rhythm control • B BLOCKER • CALCIUM CHANNEL BLOCKER • DIGOXIN • EXCEPTIONAL CASES – IV AMIODARONE Rate Control • TREAT UNDERLYING CAUSE AND RISK FACTORS Rx Comorbidities & Risk • Life style modification • Psychosocial support • Structured follow-up Supportive care
- 24. Valvular disease –MS HCM Prior stroke Score > 2 THE RISK OF STROKE BY CHA2DS2-VASC SCORE 0 NIL 2+ Oral Anticoagulant INDICATION
- 25. THE RISK OFBLEEDING HAS-BLED Score 0 NIL 3+ Close Monitoring Contraindication To Oral Anticoagulants Active Bleed/ High Risk of bleed Platelet Count < 50k, INR > 3 Creatinine Clearance < 30 ml/min
- 26. THROMBOPROPHYLAXIS Loss of atrialcontraction & Left atrial dilatation Cause stasis of blood in the LA & thrombus formation in the left atrial appendage. This predisposes patients to stroke Antiplatelet therapy should not be used for stroke prevention in Vitamin K Antagonist WARFARIN New Oral Anticoagulants Factor Xa Inhibitors RIVOROXABAN APIXABAN ENDOXABAN Direct Thrombin Inhibitor DABIGATRAN No INR monitoring Fixed Dose Less drug interactions INR: 2 to 3 Monitor INR Drug Interactions Use especially for Mitral valve disease Prosthetic Valve
- 27. Attempt to restorerhythm + achieve rate control • If troublesome symptoms to improve QoL • Symptomatic paroxysmal AF, Recurrent symptomatic persistent AF • Modifiable or correctable cause in young with short history & fewer comorbidities are candidates for rhythm control Hemodynamically unstable: Emergency - synchronized DC cardioversion Hemodynamically stable Elective - synchronized DC cardioversion (<48h) ECHO Elective - synchronized DC cardioversion (>48h) ECHO , OAC 4 weeks till 4 weeks after Pharmacological – Sick, HF, IHD – IV Amiodarone Resistant Cases – Catheter ablation Surgical therapy – MAZE
- 28. Sedate Press Sync button Applyjelly over pads and place over chest as demonstrated Select Charge 200 J Do synchronized DC cardioversion Monitor patient
- 29. IV AMIODARONE 150 mgover 10 mins infusion then 360 mg (1mg/min) over 6 hours infusion Then 540 mg (0.5 mg/min) over 18 hours infusion Class III Anti arrhythmic Drug Increase refractoriness of myocardium
- 30. Prepare – TEE,ECG, CT Angio of Heart Ablation Cath Lab Electrical mapping Ablate around pulmonary veins
- 32. Attempt to restorerhythm + achieve rate control Accept presence of AF but achieve rate control B Blocker (IV Metoprolol, IV Esmolol) (Metoprolol, Bisoprolol, Nebivolol, Carvedilol) Calcium Channel Blocker – (Diltiazem, Verapamil) Digoxin Exceptional Cases- Implant a permanent pacemaker Plus Complete AV node block with catheter ablation Last Resort - IV Amiodarone <110/min < 80/Min
- 33. Treat the coexistingillness & Risk Factors
- 34. 66 years oldMale with severe Retrosternal chest pain 1 h Pulse 150 /Min Irregular BP 140 / 70 mmHg RR 22/Min No Pedal enema, JVP not raised, Chest Clear CVS- S1 S2 irregular, No murmur
- 35. 45 year oldmale has Dyspnoea NYHA II & palpitations 6 Months ECHO - moderate MS
- 36. 62 years Female Diabetes,Hypertension – 10 years on medications. Has palpitations since 4 months. ECG show AF, ECHO is WNL