Rob fib

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Rob fib

  1. 1. Atrial Fibrillation…. Robert Minera D.O. PGY-IV ARMC Emergency Medicine
  2. 2. Atrial Fibrillation…. aka Pennington Syndrome Robert Minera D.O. PGY-IV ARMC Emergency Medicine
  3. 3. Epidemiology <ul><li>Most frequently diagnosed arrhythmia </li></ul><ul><li>Affects 2.3 million people in the US </li></ul><ul><li>Affects 1/136 people in the US </li></ul><ul><li>Incidence increases with age </li></ul><ul><li>8% of people >80 yrs. old </li></ul>
  4. 4. Signs and Symptoms <ul><li>Palpitations </li></ul><ul><li>Weakness </li></ul><ul><li>Dizziness </li></ul><ul><li>Reduced exercise capacity </li></ul><ul><li>Dyspnea </li></ul><ul><li>Asymptomatic </li></ul>
  5. 5. Etiology/Risk Factors <ul><li>Structural heart disease </li></ul><ul><li>Chronic lung disease </li></ul><ul><li>Pneumonia </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Alcohol use </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>HTN </li></ul><ul><li>Pericarditis </li></ul>
  6. 6. Differential Diagnosis <ul><li>Narrow Complex Tachycardias </li></ul><ul><ul><li>Atrial Fibrillation </li></ul></ul><ul><ul><li>Atrial Flutter </li></ul></ul><ul><ul><li>AVNRT </li></ul></ul><ul><ul><li>AVRT </li></ul></ul><ul><ul><li>Atrial tachycardia </li></ul></ul><ul><ul><li>Sinus tachycardia </li></ul></ul><ul><ul><li>Multifocal atrial tachycardia </li></ul></ul>SVT is a category, not a diagnosis!
  7. 7. ACC/AHA/ESC <ul><li>Paroxysmal: terminates in < 7 days </li></ul><ul><li>Persistent: fails to terminate within 7 days </li></ul><ul><li>Permanent: > 1 year </li></ul><ul><li>Lone: Individuals without structural heart disease, < 60 yrs old </li></ul>
  8. 8. Diagnostic Testing: EKG Narrow Complex Irregularly Irregular Rapid Ventricular Rate
  9. 9. Diagnostic Testing: TTE <ul><li>To assess for structural heart disease </li></ul><ul><ul><li>EF </li></ul></ul><ul><ul><li>Wall motion </li></ul></ul><ul><ul><li>Dilation/Hypertrophy </li></ul></ul><ul><ul><li>Size of right and left atrium </li></ul></ul><ul><ul><li>Valvular disease </li></ul></ul><ul><ul><li>Pericardial disease </li></ul></ul>
  10. 10. Chest X-Ray <ul><li>Look for emphysema/COPD </li></ul><ul><li>Cardiac borders </li></ul><ul><li>Pneumonia </li></ul>
  11. 11. Management <ul><li>Rate Control </li></ul><ul><li>Rhythm Control </li></ul><ul><li>Anticoagulation </li></ul><ul><li>Unstable patients </li></ul>
  12. 12. Rate Control <ul><li>Why is rate control important? </li></ul><ul><ul><li>Ischemia, MI, hypotension can occur </li></ul></ul><ul><ul><li>Long term: Cardiomyopathy </li></ul></ul><ul><li>Goals </li></ul><ul><ul><li>Rest HR < 80 bpm </li></ul></ul><ul><ul><li>24 Hour (Tele/Holter) < 100 bpm average </li></ul></ul><ul><ul><li>HR < 110 in 6 minute walk </li></ul></ul>
  13. 13. Rate Control (con’t) <ul><li>Medications </li></ul><ul><ul><li>Metoprolol / Esmolol: IV or Oral </li></ul></ul><ul><ul><li>Diltiazem: IV or Oral </li></ul></ul><ul><ul><li>Verapamil: Oral Only </li></ul></ul><ul><ul><li>Digoxin: Patients with hypotension </li></ul></ul><ul><ul><li>Amiodarone: Also for rhythm control </li></ul></ul>
  14. 14. Rhythm Control <ul><li>Indications </li></ul><ul><ul><li>Symptoms of a-fib persistent </li></ul></ul><ul><ul><li>To avoid long term anticoagulation </li></ul></ul><ul><ul><li>Bleeding risk </li></ul></ul>
  15. 15. Rhythm Control (con’t) <ul><li>Synchronized DC cardioversion </li></ul><ul><ul><li>Emergencies/Hemodynamic instability </li></ul></ul><ul><ul><li>Greater efficacy than medications </li></ul></ul><ul><li>Pharmacologic cardioversion </li></ul><ul><ul><li>If AF < 7days – dofetilide, flecainide, ibutilide, propaferone or amiodarone </li></ul></ul><ul><ul><li>If AF > 7 day – dofetilide or amiodarone </li></ul></ul>
  16. 16. Rate or Rhythm Control? <ul><li>AFFIRM Study: Rate versus rhythm control </li></ul><ul><ul><li>No difference in incidence of stroke </li></ul></ul><ul><ul><li>Trend towards lower mortality in the rate control group </li></ul></ul><ul><ul><li>This is STILL a controversial topic! </li></ul></ul><ul><ul><li>New study focusing on rhythm conversion- </li></ul></ul><ul><ul><li>Ottawa Protocol </li></ul></ul>
  17. 17. Anticoagulation and Cardioversion <ul><li>Afib < 48 hours: </li></ul><ul><ul><li>Cardioversion (CV) </li></ul></ul><ul><ul><li>No anticoagulation indicated </li></ul></ul><ul><li>Afib > 48 hours: </li></ul><ul><ul><li>Anticoagulate for 3-4 weeks before CV </li></ul></ul><ul><ul><li>OR get TEE </li></ul></ul><ul><ul><li>Anticoagulate for 1 month after CV </li></ul></ul>
  18. 18. Anticoagulation – Long Term <ul><li>Risk of CVA determined by CHADS2 score (CHF, HTN, >75, DM, Previous CVA x 2) </li></ul>Key Points Most patients, can wait 48 hours before starting 0-1 probably don’t need anticoagulation 5-6 should be bridged with heparin/LMWH Score Annual Stroke Risk % 0 1.9 1 2.8 2 4.0 3 5.9 4 8.5 5 12.5 6 18.2
  19. 19. Management – Unstable <ul><li>Unstable: A-fib associated with Hypotension </li></ul><ul><li>Synchronized electric Cardioversion immediately </li></ul>
  20. 20. Key Points <ul><li>MI is a rare CAUSE of a-fib </li></ul><ul><li>Rate control must be achieved during exercise, not just at rest </li></ul><ul><li>Not every patients needs to bridge with heparin </li></ul><ul><li>Unstable patients should immediately be cardioverted </li></ul>

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