2. • A 74-year-old woman presents for her annual physical examination and notes increasing
fatigue over the prior 3 months.
• Her history is notable for longstanding, but well-controlled, systolic hypertension.
• A physical examination demonstrates a blood pressure of 120/70 mm Hg and an irregular
pulse of approximately 120 bpm at rest.
• The patient weighs 60 KG with a body mass index of 22.
• The rest of her examination is completely normal with no clinical evidence of right- or
left-sided heart failure.
• The patient has no family history of coronary artery disease, cardiomyopathy or atrial
fibrillation.
• Her review of systems is notable only for fatigue without complaint of snoring, chest pain,
palpitations, weight gain or loss, orthopnea, dyspnea, peripheral edema or syncope.
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3. • A 74-year-old woman presents for her annual physical examination and notes increasing
fatigue over the prior 3 months.
• Her history is notable for longstanding, but well-controlled, systolic hypertension.
• A physical examination demonstrates a blood pressure of 120/70 mm Hg and an irregular
pulse of approximately 120 bpm at rest.
• The patient weighs 60 KG with a body mass index of 22.
• The rest of her examination is completely normal with no clinical evidence of right- or
left-sided heart failure.
• The patient has no family history of coronary artery disease, cardiomyopathy or atrial
fibrillation.
• Her review of systems is notable only for fatigue without complaint of snoring, chest pain,
palpitations, weight gain or loss, orthopnea, dyspnea, peripheral edema or syncope.
5. Tests including complete blood count, electrolytes, HbA1c
and liver function to eliminate potential causes of fatigue
were within normal limits.
An confirms the diagnosis of atrial fibrillation with a
rapid ventricular response of 120 bpm and criteria for left
ventricular hypertrophy.
6. o An done a year earlier to evaluate left ventricular
hypertrophy was notable only for mild, global left ventricular
dysfunction with a left ventricular ejection fraction of 40% and
mild mitral regurgitation.
o A subsequent showed no evidence of myocardial
ischemia.
o The patient’s includes lisinopril 20 mg, metoprolol XL
25 mg and 81 mg aspirin daily.
A repeat performed in the office demonstrates an ejection
fraction of 20% but normal left ventricular dimensions with normal
pulmonary arterial systolic pressure.
BEFORE
NOW
7.
8. 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 calcium-channel blockers (e.g., verapamil
or diltiazem), but it can be considered if blood
pressure is low.
11. Q. Should you restore sinus rhythm or choose a
strategy of rate control?
Rate vs. Rhythm Control
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.
12. If the decision is made to maintain sinus rhythm after the
cardioversion, what are the best medical or procedural options?
13. Q. What are the anticoagulation
requirements for this patient?
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
Past stroke or TIA
Female sex
Vascular disease
14.
15. In this case the risk factors for
stroke:
including sex
age
hypertension
16. All together mandate chronic anticoagulation regardless of the
decision for rhythm or rate control.
The choices for anticoagulation include warfarin with a target INR
of ? or NOACs
In this case the risk factors for
stroke:
including sex
age
hypertension
18. The decision for Rate control was made with an increased
dose of metoprolol but was limited by hypotension.
19.
20. 20
As a consequence, a TEE (trans-esophageal echo) was
performed to exclude an existing thrombus and allow
cardioversion.
The procedure demonstrated a clear left atrium and this
allowed DC cardioversion to be performed safely.
The decision to maintain sinus rhythm or choose a strategy of rate control is generally based on how easily symptoms can be mitigated with rate control. If the rate is easily controlled, it is reasonable to forego cardioversion. Conversely if the rate is difficult to control and the patient has progressive symptoms including those of heart failure, a strategy of cardioversion and maintenance of sinus rhythm is preferred.
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.
