Afib stands for atrial fibrillation (AF), which is a type of arrhythmia, or abnormal heartbeat. Afib is caused by extremely fast and irregular beats from the upper chambers of the heart (usually more than 400 beats per minute). A normal, healthy heartbeat involves a regular contraction of the heart muscle

1. EVALUATION OF
ATRIAL FIBRILLATION
JENISH G CHRISTIN BSC RN.RM

2. • Introduction
• Epidemiology
• Morbidity and Mortality
• Risk Factors
• Conditions associated with A fib
• Classification
• Pathophysiology
• Clinical evaluation
• Diagnostic evaluation
• Management
• Conclusion

3. Introduction
• Atrial fibrillation is the most sustained common arrhythmia
• It has strong associations with other cardiovascular diseases,
such as heart failure, coronary artery disease, valvular heart
disease, diabetes mellitus, and hypertension
• It is the leading cardiac cause of stroke

4. Atrial Fibrillation
• A supraventricular tachyarrhythmia with uncoordinated atrial
activation and ineffective atrial contraction
• It results in disorganized atrial electrical activity and an irregular
ventricular rhythm
• This causes increased rate of stroke, heart failure, and mortality

5. Epidemiology
• Globally
- According to the global burden of disease, In 2019, here was a
total of 33.31 million A fib cases, with 219 thousand deaths
• USA
- In 2010 it was estimated that >5 million people had A fib (Go As et
al)
• Europe
- Prevalence of A fib in 2010 was 9 million among individuals
older than 55 years (Krijthe BP et al)
• Sub Sahara Africa
- No reliable data

6. Morbidity and Mortality
• Afib is associated with a 1.5 to 2 fold increased risk of death
(Odutayo A et al)
• Afib is associated with increased risk of multiple adverse
outcomes:
- A 2.4 fold risk of stroke
- A 1.5 fold risk of cognitive impairment or dementia
- A 1.5 fold risk of myocardial infarction
- A 2 fold risk of sudden cardiac death

7. - A 1.6 fold risk of chronic kidney disease
- A 1.3 fold rsik of peripheral artery disease
- A 5 fold risk of heart failure
• In a study by Piccini et al, the most frequent outcome in the 5
years after Afib diagnosis was death, then heart failure,
followed by new- onset stroke, gastrointestinal haemorrhage
and myocardial infarction, respectively

8. Risk Factors
• Advancing age
• Smoking (current smoking increases risk by 9.8%)
• Sedentary lifestyle
• Alcohol (increase risk of Afib in 4 hours after a single binge
drink)
• Adiposity markers: weight, BMI, obesity
• Height
• Hypertension
• Diabetes
• Genetics

9. Cardiovascular Diseases Associated
with Afib
• Heart failure
• Coronary heart disease
• Valvular heart disease
• Cardiac surgery: CABG, pericardiotomy, aortic valve surgery

10. Other Conditions Associated with Afib
• Chronic Kidney Disease
• Obstructive sleep apnea
• Thyroid disease: Hyperthyroidism
• Sepsis

11. Classification
• Stage 1: At risk for Afib
- Presence of modifiable and non modifiable risk factors associated wit
Afib:
- Modifiable risk factors: Obesity, lack of fitness, hypertension, sleep
apnea, alcohol, diabetes
- Nonmodifiable risk factors: Genetics, male sex, age

12. • Stage 2: Evidence of structural or electrical finding further
predisposing a patient to Afib:
- Atrial enlargement
- Frequent atrial ectopic beat
- Short bursts of atrial tachycardia
- Atrial flutter

13. • Stage 3: Atrial Fibrillation
Patient may transition among different substages of Afib
 3A: Paroxysmal A fib: Intermittent and terminates within </=
7 day of onset
 3B: Persistent A fib: Continuous and sustains for > 7day and
requires intervention
 3C: Long-standing persistent A fib: Continuous for > 12
month in duration
 3D: Successful A fib ablation: Freedom from A fib after
percutaneous or surgical intervention to eliminate A fib

14. • Stage 4: Permanent A fib
• No further attempts at rhythm control after discussion between
patient and clinician

16. Mechanism and Pathophysiology
• A fib is a chaotic, rapid (300-500 bpm), and irregular atrial
rhythm
• Normal rhythms are conducted through the atria in smooth
waves initiated by the sinoatrial node, A fib is the result of:
- Electrophysiological abnormalities that underlie impulse
generation
- Structural abnormalities of cellular connections that typically
facilitate rapid and uniform impulse conduction

17. • A fib often stems from waves of electrical activity originating
from ectopic action potentials most commonly generated in the
pulmonary veins of the left atrium or in response to reentrant
activity promoted by heterogeneous conduction due to
interstitial fibrosis

19. Clinical Evaluation
• History
- Asymptomatic
- Symptomatic:
oPalpitations
oDyspnea
oDizziness
oFatigue
oNeurological deficit
oChest pain
oSymptoms of decompensated heart failure

20. • Patients should be assessed for
- Duration, and frequency of symptoms
- For precipitating factors (exertion, sleep, caffeine, alcohol use)
- Documentation of prior use of antiarrhythmic and rate-
controlling agents
- Presence of underlying heart disease
- Any previous surgeries on the heart
- Any previous surgical or percutaneous AF ablation procedures

21. Physical Examination
• Vital signs ( hemodynamic stability)
- Pulse rate: irregularly irregular
- Heart rate ( tachycardic within 110-140 b/m range)
- Blood pressure
- Respiratory rate
- Oxygen saturation

22. • Head and Neck Examination
- Exophthalmos
- Thyromegaly
- Elevated jugular venous pressure
- Carotid artery bruits
• Pulmonary Examination
- Evidence of heart failure
- Diminished breath sound

23. • Cardiac Examination
- A displaced point of maximal impulse
- S3
- Murmurs
• Abdominal Examination
- Ascites
- Hepatomegaly
- Left upper quadrant pain (splenic infarct from peripheral
embolization)

24. • Lower Extremities
- Edema
- Cool or cold pulseless extremity: peripheral embolization
• Neurologic Examination
- TIA
- Cerebrovascular accident

25. Risk stratification and population
screening
- The most widely replicated risk predication model for A fib is
CHARGE-AF (Cohorts for Heart and Aging Research in
Genomic Epidemiology model for atrial fibrillation)
- Most screening trials have shown higher A fib detection using
intermittent or continuous electrocardiographic recordings and
higher A fib detection in patients with higher predicted risk for
AF

26. • Age (per 5 year increment)
• White race
• Height ( per 10cm increment)
• Weight (per 15 kg increment)
• Systolic BP (per 20mmHg increment)
• Diastolic BP (per 10 mmHg increment)
• Smoking
• Diabetes
• Myocardial infarction

27. Diagnostic Evaluation
• 12 lead ECG
- Usually confirms the diagnosis of atrial fibrillation
- Ventricular rate is irregular (irregular QRS complexes)
- Discrete P waves are absent, replaced by irregular, chaotic F
waves
- Heart rate is typically in the 110-140 range

29. • ECG can also indicate underlying various cardiac disease
- Left ventricular hypertrophy
- Bundle- branch block
- Acute or prior myocardial infarction
- Co- existing atrial arrhythmias
• Aside 12 lead ECG, monitoring option for AF include
continuously recording electrocardiographic monitors,
implantable cardiac monitors, handheld ECGs, and smart
watches.

30. • Laboratory Studies
- Complete blood count (anemia, infection)
- E, U Cr (renal failure)
- Cardiac enzymes level: Creatine kinase, troponin level ( MI as a
primary or secondary event) if signs and symptoms are present
- B-type natriuretic peptide (BNP) level ( to evaluate for CHF) if
signs and symptoms are present
- Thyroid function studies
- Toxicology testing or ethanol level

31. • Echocardiography
- Transthoracic echocardiography is helpful in evaluating for
valvular disease, left and right atrial size, left ventricular size
and function, left ventricular hypertrophy, pericardial disease
- Transesophageal echocardiography is helpful for evaluating for
atrial thrombus (particularly in the LA appendage)

32. Management
 Lifestyle and Risk Factor Modification
Primary Prevention
- Patients at increased risk of AF should receive comprehensive
guidline- directed lifestyle and risk factor modification to
reduce the risk of A fib
- Includes:
- Maintenance of ideal weight and weight loss if overweight or
obese
- Pursue a physically active lifestyle
- Receive smoking cessation counselling and/or medication

33. - Moderate intake or abstain from alcohol and avoidance of
binge drinking
- Avoid recreational substances such as cannabis, cocaine,
methamphetamine, opiate use.

34. • Secondary Prevention : Management of comorbidities and
risk factors
- In patient with Afib, who are overweight or obese with BMI > 27
kg/m2, weight loss is recommended, with an ideal target of at
least 10% weight loss to reduce the Afib symptoms
- In patients with Afib, moderate to intense exercise (aerobic)
training to a target of 210 minutes per week is recommended to
reduce Afib symptoms and burden

35. - In individuals with Afib, cigarette smoking was associated with
poorer outcomes including worse cardiovascular outcomes
and death
- Patients with Afib should minimize or eliminate alcohol
consumption to reduce Afib burden
- Patient with Afib and hypertension should have optimal control
of BP to reduce Afib recurrence and Afib related cardiovascular
events

36.  Prevention of Thromboembolism
- Patients with Afib should be evaluated for annual risk of
thromboembolic events using a validated clinical risk score,
such as CHA2 DS2 VASc
- Patients with Afib should be evaluated for factors that
specifically indicate a higher risk of bleeding. Bleeding risk
scores is used such as HAS-BLED
- In patients who are deemed at high risk of stroke, bleeding risk
scores should not be used in isolation to determine eligibility
for oral anticoagulation but instead to identify and modify
bleeding risk factors

37. • C- Congestive heart failure 1
• H- Hypertension 1
• A2- Age >/= 75years 2
• D- Diabetes 1
• S2- Thromboembolism 2
• V- Vascular disease 1
• A- Age 65-74 year 1
• S- Sex category (female sex)1
- Score >/= 2 in men and >/= 3 in woman merits anticoagulants.
- In patients with low bleeding score, anticoagulation can be
started in men with score >/= 1 and in women with score >/= 2

38. • Hypertension 1
• Abnormal renal and liver function (1 points each) 1 0r 2
• Stroke 1
• Bleeding 1
• Labile INRs 1
• Elderly (age >65 years) 1
• Drugs or alcohol (1 point each) 1 or 2
- 0: low risk
- 1 -2: moderate risk
- >/=3 : high risk

39. Oral Anticoagulants
• Vitamin K Antagonist: Warfarin
- First line therapy in patients with Afib and moderate-severe
rheumatic mitral stenosis or mechanical heart valves
- Target INR 2 and 3
• Direct oral anticoagulants (DOACs)
- The first line therapy in patients with Afib except moderate to
severe mitral stenosis or mechanical heart valve
- Apixaban, dabigatran, rivaroxaban, edoxaban

40. • Dabigatran:
- CrCl > 30mL/min: 150mg bd
- CrCl 15 -30mL/min: 75mg bd
• Rivaroxaban
- CrCl >50mL/min : 20mg daily
- CrCl 15-50mL/min: 15mg daily
• Apixaban: 5mg bd
• Endoxaban
- CrCl > 50 - <95 mL/min: 60mg daily
- CrCl 15 – 50mL/min: 30mg daily

41. Non pharmacological stroke prevention
• Used in patient who have contraindication to oral
anticoagulation use
• This include surgical or percutaneous techniques to occlude
the left atrial appendage (LAA)
• Percutaneous Left Atrial Appendage Occlusion (PLAAO)
devices are designed to prevent embolization of LAA thrombi
and also obviate the need for oral anticoagulants for stroke risk
reduction

42. Rate Control
• The aim of rate control in a patient with Afib: To reduce and
control symptoms and reduce the risk of developing LV systolic
dysfunction
• In patients with AF without HF, heart rate should be aimed at a
resting heart rate of < 100 to 110 bpm
• In patients with Afib with rapid ventricular response who are
hemodynamically stable: beta blockers or nondihydropyridine
calcium channel blockers, provided that EF >40% are
recommended

43. • In patients whom beta blockers and nondihdropyridine calcium
channel blockers are ineffective or contraindicated, digoxin,
intravenous amiodarone may be considered

44. • Beta Blockers
- Metoprolo tartrate: 25 – 200mg twice daily
- Metoprolol succinate: 50 – 400mg daily or twice daily in divided
doses
- Atenool: 25 -100mg daily
- Bisoprolo: 2.5 -10mg daily
- Carvedilol: 3.125 – 25mg twice daily

45. • Nondihydropyridine Calcium Channel Blockers
- Diltiazem: 120-360mg daily
- Verapamil: 180 -480mg daily
• Digitalis glycoside
- Digoxin: 0.0625 – 0.25mg daily
• Other
- Amiodarone: 100 – 200mg daily

46. Rhythm Control
• In patients with reduced LV function and persistent Afib, a trial
of rhythm control should be recommended to evaluate whether
Afib is contributing to the reduced LV function
• In patients with symptomatic Afib, rhythm control can be useful
to improve symptoms
• In patients with a recent diagnosis of Afib (< 1 year), rhythm
control can be useful to reduce hospitalizations, stroke, and
mortality
• In patients with Afib and heart failure, rhythm control can be
useful for improving symptoms and outcomes such as mortality
and hospitalizations

47. Cardioversion
Used to restore regular heart rhythm
• Electrical cardioversion: Synchronized administration of shock
during R waves or QRS complex. Uses low energy
• Pharmacological cardioversion
• In hemodynamically unstable patients, electrical cardioversion
is the treatment of choice
• In hemodynamically stable patients, both electrical and
pharmacological cardioversion are acceptable, safe and
efficacious methods for acute rhythm control
• Electrical cardioversion is more effective than pharmacological
cardioversion

48. • Prevention of Thromboembolism in the setting of
Cardioversion
- In patients with Afib duration of < 48 hours, and who are not on
anticoagulation, should have an ECHO done to exclude
intracardiac thrombus before cardioversion is done
- In patients with Afib duration of >/= 48 hours, a 3 week
duration of uninterrupted therapeutic anticoagulation or
imaging to exclude intracardiac thrombus is recommended
before elective cardioversion
- Anticoagulation is continued for at least 4 weeks after
cardioversion without interruption to prevent thromboembolism

49. • Electrical Cardioversion
- In patients with hemodynamic instability attributable to Afib,
immediate electrical cardioversion should be performed to
restore sinus rhythm
- In patients with Afib who are hemodynamically stable, electrical
cardioversion can be performed as initial rhythm-control
strategy or after unsuccessful pharmacological cardioversion
- A direct current of biphasic energy of 200J is delivered to
synchronize with QRS to reduce the risk of inducing VF

50. • Pharmacological cardioversion
- Used in hemodynamically stable patients
- Drugs used:
- IV Ibutilide: Works rapidly
- IV amiodarone: requires longer time for cardioversion (8 to 12
hours)
- Flecainide
- Propafenone

51. • IV Ibutilde:
- >/= 60kg: 1mg over 10 mins
- <60g: 0.01mg/kg over 10 min
• IV Amiodarone:
- Loading dose: 5 -7 mg/kg or 300mg
- Maintenance dose: 1200 – 3000 mg in continuous infusion over
24 hours

52. • Oral Flecainide
- < 70kg: 200mg single dose
- > 70kg: 300mg single dose
• IV Procainamide
- Loading dose: 1g over 30 mins
- Maintenance dose: 2mg/min continuous infusion over 1 hour
• Oral Propafenone
- < 70kg: 450mg single dose
- >70kg: 600mg single dose

53. • Specific Drug Therapy for Long- Term Miantenance of
Sinus Rhythm
- Patients with Afib with HFrEF < 40%: Dofetilide or amiodarone
- Patients with Afib and no previous MI, or known structural heart
disease: Flecainide or propafenone
- Patients with Afib without recent decompensated HF or severe
LV dysfunction: Dronedarone
- Patients with Afib and normal LV function: Low dose
amiodarone

54. • Amiodarone
- Loading dose: 400 – 800mg daily in 2-4 divided doses for 1 – 4
weeks
- Maintenance dose: 200mg daily
- Dofetilide
- CrCl >60mL/min: 500microg twice daily
- CrCl 40 -60 mL/min: 250 microg twice daily
- CrCl 20-40mL/min: 125microg twice daily
- Dronedarone: 400mg twice daily
- Flecainide: 50 – 300mg per day
- Propafenone: 150 – 300mg 8 hourly

55. A fib Catheter Ablation
• Used for rhythm control in patients with symptomatic Afib in
whom anti-arrhythmic drugs have been ineffective,
contraindicated, not tolerated
• Can be used as first-line therapy in selected patients (younger
patients with few comorbidities) with symptomatic paroxysmal
Afib
• In patients who have undergone catheter ablation, oral
anticoagulant should be used for at least 3 months after the
procedure

57. Conclusion
• The significantly increasing incidence, prevalence, and high
lifetime risk render AF a relevant disease in the population with
high morbidity, mortality, and significant health care costs.
• Identification and targeting modifiable risk factors might be
considered as the most relevant investment for AF risk
modulation, number of lives saved, and healthcare resources
freed

58. Thank you for listening!!!

59. References
• Krijthe BP, Kunst A, Benjamin EJ, Lip GY, Franco OH, Hofman A, Witteman JC, Stricker
BH, Heeringa J. Projections on the number of individuals with atrial fibrillation in the
European Union, from 2000 to 2060.Eur Heart J. 2013
• Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of
diagnosed atrial fibrillation in adults: national implications for rhythm management and
stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA)
Study.JAMA. 2001
• Odutayo A, Wong CX, Hsiao AJ, et al. Atrial fibrillation and risks of cardiovascular disease,
renal disease, and death: systematic review and meta-analysis.BMJ. 2016; 354:i4482
• Piccini JP, Hammill BG, Sinner MF, et al. Clinical course of atrial fibrillation in older
adults: the importance of cardiovascular events beyond stroke.Eur Heart J. 2014;
35:250–256
• 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial
Fibrillation: A Report of the American College of Cardiology/American Heart Association
Joint Committee on Clinical Practice Guidelines. José A. Joglar, Mina K. Chung,
Anastasia L. Armbruster, et al. AHA journal, 2023