This document discusses the management of atrial fibrillation (AF). It outlines the goals of management which are to prevent stroke, cardiomyopathy, relieve symptoms, and improve survival. The main strategies for management are rate control, rhythm control, and prevention of thromboembolism. Rate control is recommended for all AF patients using medications, while rhythm control is only recommended for selected patients. Risk stratification is important for determining anticoagulation and cardioversion approaches. Electrical and pharmacological cardioversion can be used to restore normal sinus rhythm but have varying success rates depending on the duration and chronicity of AF.

1. ATRIAL FIBRILLATION Dr. Nagula Praveen

3. Prevention of tachycardia induced cardiomyopathy

4. Symptom relief

5. Improved survival

7. Rhythm control – in selected patients with AF

9. 1.ANTIARRHYTHMIC DRUGS

10. 2.AV NODAL BLOCKING DRUGS

11. 3.ACEI

12. 4.ARBS

13. 5.STATINS

14. 6.FATTY ACIDS

15. 7.STEROIDS

16. SURGICAL —MAZE PROCEDURE

17. ABLATION

18. PACEMAKER

21. 15- 20 times the nonvalvular

22. Prosthetic valves 2.5-3.5

23. MVR – 2.0- 3.0

25. Diabetes

26. Age

28. CHA2DS2VASc SCORE

29. THERAPY ACCORDING TO RISK FACTORS

31. Unstable thrombus – dislodge on contraction.

32. Atrial mechanical function lags behind electrical function.

33. Atrial mechanical stunning --- 4 weeks JACC 1989

35. Empiric anticoagulation for 3 weeks.

36. Short term anticoagulation : TEE guided

37. Why 3 weeks – organisation of thrombus

38. Warfarin?--- target 2.5

39. Do weekly INR before cardioversion.

40. Low INR more events JACC;2002;40(5)

41. Heparin followed by TEE – thrombus present --- warfarin for three weeks .

42. Post cardioversion for 4 weeks.

44. Not needed in < 48 hrs.

46. Disadvantage of OAC

47. Inter individual variation

48. Drug /food interactions

49. Regular INR check up needed--- monthly.

50. DABIGATRAN (pradaxa)--- direct thrombin inhibitor

51. REL –Y trial --- same as warfarin in stroke prevention

52. Higher dose more effective but with risk of bleeding.

53. No INR monitoring,150-220 mg daily

54. FDA approved------- NEJM 2009 361(2);1139-51

55. RIVAROXABAN (xaretto)--- factor X a inhibitor

56. Related to linezolid,mitochondrial toxicity

58. WATCHMAN device

59. PROTECT AF trial

60. Periprocedural complications more

61. Used when OAC contraindicated

65. Beta blockers

66. Amiodarone

67. DigoxinABCD

68. Rate control Bblockers , CCBs , digoxin are effective for rate control. Do not convert AF into NSR. C/I in pre excitation Amiodarone for both rate and rhythm control. Several side effects limits its use as first line drug. Choice of drugs depends upon the clinical presentation

72. 0.25 mg /kg (15-20 mg ) given IV over 2 minutes.

73. Monitor HR and BP

74. Rapid onset of action –within 10 min

75. 0.35 mg /kg (20-25 mg )IV over 4 min

76. HR < 100bpm ---maintenance dose 5-15 mg /hr is infused

77. t1/2 3-4 hrs

78. Oral dose within 3 hrs of IV dose.

79. 1.5 * total IV dose

80. 120-360 mg three to four divided doses

82. Same if needed after 15 to 30 min

83. T ½ -- 4-12 hrs.

84. No need of continuous maintenance infusion

85. More hypotensive and more negatively inotropic than diltiazem.

86. Hypotension responds to IV calcium gluconate 1 gm.

88. Thyrotoxicosis

89. Class I recommendation

90. Metoprolol:

91. Selective B1 blocker

92. 2.5 -5 mg IV over 2 min .. Up to three doses ( max 15 mg)

93. Oral maintenance dose of 25-100mg (50 mg) bid

94. Atenolol– use in hypertension 5mg IV—50 mg od

95. Propanolol – 0.15 mg /kg -- 80 -240 mg /day

97. In hypotension

98. In COPD

99. LVD

100. Class 1 recommendation

101. Not effective as monotherapy.

104. 0.25 mg IV over 2 min every 2 hours.

105. Not to exceed 1.5 mg IV over 24 hrs

106. Maintenance dose is 0.125-0.375 mg daily IV or orally.

107. Orally 0.5 mg daily for 2-4 days— 0.125– 0.375 mg daily

108. Slow onset of action

109. Effective in controlling heart rates at rest as well as in individuals who are sedentary

111. 150 mg IV over 10 min

113. Oral dose is 800 mg /day in divided doses /week

114. Oral maintenance dose 200mg daily.

116. Allows the fibrillatory waves to pass freely through the bypass tract--- VF

117. Type Ia agents which increase refractory period of bypass tract –procainamide

118. Inhibit both AV node and bypass tract– type Ic and type III ibutilide or amiodarone IV to control ventricular rate.

121. HOLTER MONITROING rest --- < 80/min

122. no hour averaging ----- 90 / min

123. Moderate exercise 90 – 115 /min

124. Peak exercise 120 /min

125. 20- 30 % REDUCTION of age predicted HR

127. In AFFIRM trial (Atrial Fibrillation Follow up Investigation of Rhythm Management)

128. RACE Rate control vs Electrical Cardioversion for Persistent Atrial Fibrillation

129. No change in mortality or incidence of stroke in both groups.

131. Increased if > 48 hrs.

132. Spontaneous conversion – many patients of AF

133. Mostly during the first 24-48 hrs.

134. Less as duration prolongs

135. Very less > 7 days

137. When?

138. Which is better?

139. In whom?

140. When --- symptomatic AF,newlyAF,post op AF

141. Which -------- electrical > pharmacological

143. “restoration of SR is a reasonable goal in patients who have a first time diagnosis of AF regardless of symptoms unless some indications shows that AF has been prsent for many years before identification…….” CARDIOLOGY CLINICS

145. Effective in short duration AF

146. Not useful in old , asymptomatic

147. Therapeutic anticoagulation in all..

148. Biphasic > monophasic

150. Biphasic > monophasic

151. Deep sedation required.

152. No effect of pad size or paddle positioning.

153. Shock delivery not during vulnerable phase---VF

154. In synchronized mode— R wave sensing.

155. In defibrillation mode --- in an asynchronous fashion.

156. 200/360 J

158. Why?--- no effect on device.

159. Device commanded cardioversion.

160. In AFL –antitachycardio pacing is required,no sedation.

162. IRAF

163. Failed cardioversion

164. IRAF---immediate recurrence of AF

165. 5%-25%

166. Triggered by APCs

167. Pretreatment with fleicainide useful.

168. Failed cardioversion – 10 %

171. Less symptoms

172. Good effort tolerance

173. Less hospitalisations

177. < 7 days of onset

178. Less effective than electric

179. Toxic effects of drugs

180. Type Ia agents – procainamide,quinidine,disopyramide

181. Type Ic agents – propafenone , fleicainide

182. Type IIIagents -- ibutilide, dofetilideamiodarone

183. Hospitalised

185. Class I recommendation

186. Class Icfleicainide or propafenone

187. Class IIa Class III dofetilide or ibutilide

188. Class IIb – amiodarone

190. Orally or IV

191. 200-300 mg given once

192. Only after effective response in hospitalisation –pill in pocket approach to be used.

194. Oral –600mg given once

195. IV dose 1.5-2.0 mg /kg over 10-20 min

197. 1 mg over 10 min

199. 500 mcg bid

200. 500-100 mcg daily

202. 1.2 -1.8 g/day of infusion—10 gms

205. 100-400 mg daily

206. >7 days:

209. Adjunctive therapy

210. For short duration –class Ic drugs

211. Pill in pocket approach only after intial hospital response --- based on symptoms prsent outside,

212. >70 kg--- flecainide 300mg, propafenone 600mg

213. <70 kg --- flecainide 200 mg , propafenone 450 mg

215. In conjunction with other surgical operations

216. Replacemnt of mirtal valve

220. OMEGA 3 FATTY ACIDS

221. VITAMIN C

222. STEROIDS

223. RANOLAZINE-RANEXA

225. Amiodarone like compound

226. Lacks iodine moiety

227. Spans all classes

228. K currents,INa,Ikr,Ikach,L type ca ,βblocking,prolongs AP,

229. T ½ --24 hrs

230. Dronedarone AF study after EC—prevention of AF 800mg optimal dose.

231. ANDROMEDA study– tolerability in CHF

232. DANE trial

233. ADONIS,EURIDIS

235. Benzofuran derivative

236. Structurally related to amiodarone

237. Inhibits k currents

238. 300mg or 600 mg.

239. ATI 2001

240. Synthetic analogue of amiodarone

241. More potent than amiodarone in atrial properties

244. Decreases rate

245. Increases AP in atria

246. Antianginal drugBERTOSAMIL on clinical trials

248. Na ,k blockers

249. Atrial selectivity

250. 61 % conversion

251. 3mg/kg over 10 min --- 2 mg /kg

252. Dysguesia,nausea,vomting

253. AVE 0118

254. Ikur,ito,ikach

255. No QT prolongation

256. AZ7009

257. SEROTONIN type 4 antagonists

259. Slowed av conduction

260. No negative inotropic ,vasodialtion,hypotension effects.

261. Ambasilide

262. Almokalant

263. Sematilide

264. Tedisamil

265. Ximelgatran –SPORT IF trial

268. WHAT DOES TRIALS SAY? AFFIRM trial : RACE trial : AF –CHF trial ALL reveal no change in mortality in both groups. Treatment is individuialised

269. AFFIRM trial : management of AF with the rhythm control strategy offers no survival advantage over the rate control strategy.anticoagualtion to be continued in this group of high risk patients . ATHENA trial :a trial with dronaderone to prevent hospitalisation or death in AF 400mg bid dose ANDROMEDA –european trial of dronedarone in moderate to severe CHF---400 mg bid CAFÉ trial : canadian AF evaluation study. SAFIRE –D study –doefetilide use in AF 500ug dose. CRAFT REL-Y TRIAL 110mg -150 mg of dabigatran. RECOVER –in dvt ROCKET AF –rivaroxaban EINSTEIN ---vte ATLAS ACS –in ACS

272. 1.Apixaban– novel factor X a inhibitor

273. 5mg bid

274. AVERROES study –phase III

275. Compared with aspirin

276. Double blinded RCT

277. 2.efficacy of olmesartan in paroxysmal AF

278. ANTI PAF trial –40 mg OD

279. 3.EPLERAF study ---eplerenone in the prevention of AF recurrence after cardioversion

280. 4.vernakalant hcl efficacy in AF

281. 5.WISDOM trial –withdrawal or continuation of amiodarone in successfully treated patients with persistent AF

283. Dronedarone not to be used in LVD

284. Catheter ablation –class Ia –A evidence in paroxysmal Afnormalatria,class II b --- paroxysmal with LVD,Iia –persistent

286. All three properties of arryhtmia play a role.

287. Foci of intiation diagnosed.

288. Treatment depends upon duration.

289. Treatment changes on age,presence of LVD

290. Anticoagualtion or antithrombotic based on assessment of risk factors..

291. Rate control = rhytm control on long term

292. theoretically rhythm control is better.

293. Not useful in permanent AF.

294. Catheter ablation is becoming the major option in treatment.

295. Effects of antiarryhthmic drugs are overcome by new drugs.

297. Ganong Samson and wright physiology Guyton www.emedicine.com www.aha.org www.atrialfibrillation.com And finally I landed up in AF ---DOCTORS SYMDROME….THANK YOU for your attention

298. Professor: define seminar Student :seminar is defined as process in which one spoils his sleep for one night in an effort to make others sleep.

299. Thank you Dr.P.L.JOHN ISRAEL H.O.D OF GENERAL MEDICINE

300. Thank you