Atrial Fibrillation

Current Management Strategies

Overview

• 25% will develop AF during lifetime• 4% above 60• 8% above 80• Total sufferers to double by 2050• Doubles annual risk of death

(Framingham)• 5% annual risk of stroke

Definitions

• Paroxysmal AF– Under 7 days– 2 or more episodes

• Persistent AF– 7 days to 1 year

• Permanent AF– Over 1 year with/without intervention– Accepted for rate control

Pathophysiology

Supraventricular ectopic focus with permissive atrial substrate

Younger

Myocytes in pulmonary veinsDrugs and alcoholMetabolic abnormalitiesElectrolyte abnormalitiesSepsis

Older

LVH/aortic stenosisAtrial ischaemia and IHD

Mitral stenosis/incompetence

HypertensionCatecholamine drive

Sepsis

Two Considerations

• Reduce ventricular rate– Cardiovert– Slow

• Prevent thromboembolism– Cardiovert – Anticoagulate

Treatment Strategies

Rhythm Control

YoungerFirst presentation

Underlying cause treatedSymptomaticHeart Failure

Rate Control

OlderCoronary artery disease

Contraindications to cardioversion

Previous failure

Paroxysmal PermanentPersistent

Rhythm Control

Rate ControlFailure

Symptoms Persist

Rhythm Control – Paroxysmal AF

• All need assessment for anticoagulation

• May need cardioversion (but aim to avoid)

• Pill in pocket may be appropriate (flecanide)

• Standard beta-blocker first line (bisoprolol)

• If failure:– CAD – Sotalol– LVD – Amiodarone

Rhythm control – Persistent AF

Onset < 48 hours

Electrical

Outpatient Management

Emergency Department

Chemical

Amiodarone

Flecanide

Heparinise

Sotalol or Amiodarone

Failure likely?

Warfarinise

Rate Control

Rate control – Persistent or Permanent

• All patients need assessment for anticoagulation

• Aim for rate under 100 (may need nothing)

• Beta-blocker of calcium channel antagonist

• Add digoxin if further control necessary

Thromboembolism

• Ineffective atrial contraction• Venous pooling in atrial appendage• Embolism

CHAD2Vasc

• Congestive Cardiac Failure• Hypertension• Age > 75 (2) > 65 (1)• Stroke/TIA/DVT/PE (2)• Vascular disease• Diabetes• Female 0 – Low risk

1 – Moderate risk

> 2 high risk

European Society of Cardiology

High Risk

CVATIAVTE

Medium Risk

> 75HTN

EF < 35%DM

No Risk

Warfarin Aspirin

Ablation/MAZE procedure

• 1:1000 death• 1:50 complications• 60% success

Case 1

• 40, fit and healthy, normal ET, normal resting ECG

• Onset AF@135bpm 24 hours ago, first event• Haemodynamically stable• Bloods normal

Anticoagulant?

Maintenance?

Cardioversion?

Heparin then Aspirin 75mg

Pill in pocket

Flecanide 300mg

Case 2

• 60, on carbimazole and bendroflumethiazide

• AF for 24 hours, otherwise normal examination

• All bloods normal including TFTsAnticoagulant?

Maintenance?

Cardioversion?

Heparin then warfarin

Bisoprolol

Electrical (not amiodarone)

Case 3

• 28 fit and well, onset AF 3 hours ago• Mild symptoms, examination normal• Bloods normal

Anticoagulant?

Maintenance?

Cardioversion?

Heparin then aspirin

Pill in pocket

Not today, return starved tomorrow

Case 4

• 89, SOB, tachycardic, febrile, cough• Raised WCC and ARF and

hypokalaemia

Anticoagulant?

Maintenance?

Cardioversion?

Probably

Review prior to discharge

Not until treated

Case 5

• 80, hypertensive, smoker with COPD• Incidental finding, symptom free• Rate 110bpm

Anticoagulant?

Maintenance?

Cardioversion?

Warfarin

Diltiazem

No

Case 6

• 50, AF 8 hours, ejection systolic murmur

• Bloods normal

Anticoagulant?

Maintenance?

Cardioversion?

Heparin then aspirin

Bisoprolol

Amiodarone

Case 7

• 50, AF 8 hours, ejection systolic murmur

• Bloods normal

Anticoagulant?

Maintenance?

Cardioversion?

Heparin then aspirin

Bisoprolol

Amiodarone