“first episode” vs. Recurrant
Atrial fibrilationinformation sources: Hurst’s THE HEART and UpToDate articles
titled:
New Onset Afib and Cardiovascualr Effects of Obstructive Sleep Apnea
Afib or Aflutter?
Types
• Paroxsysmal: <7 Days (usually <24h)
• Persistant: > 7 Days• Requires pharmacologic or electrical
cardioversion
• Permanent• Failed Cardioversion• Stretch receptors in LV: direct relationship
Work up & DDx
• Rule out potentially reversible causes• Hyperthyroid• Electrolyte abnormalities• Holiday Heart Intoxication• Acute Ischemia (cath lab)• Infection• Acute Pericarditis
• Irreversible causes• Renal failure• CHF: Echo
Treatment of AFib
• No one ideal therapy for all patients• No therapy, allow A Fib• Anticoagulation (Coumadin)• Rate Control (Metoprolol, diltiazem, digoxin)
<110 bpm• Rhythm Control (Amiodarone, Flecainide, Sotolol)
• AV node ablation
• Cardioversion • Electrical• Pharmacologic: ex: Irbesartan (ARB), Procainamide,
and other Rhythm control drugs
Indications for EmerGent Cardioversion
• Active ischemia
• Evidence of organ hypoperfusion
• Pulmonary edema
• Atrial Tachycardia (rate >250 bmp) • Accessory pathway
• <48hours: Heparin• Unless CHADS2 score 0-1
Cardiovascular effects of
Obstructive Sleep Apnea
The connection
• Patients with OSA have increased prevalence and incidence of Systemic HTN• Apnea Hypopnea Index: >15 events/hour = 3x
the HTN
• More severe the OSA= More severe HTN
• Treatment with CPAP can lower Systemic BP• But not enough to avoid antihypertensive
medications
Further implications
• Corresponding daytime hypoxia (ex: COPD) • or excessive daytime sleepiness (with continued
hypoxia/hypercapnea from naps)
• = Worse Cardiovascular effects from OSA
• And possible Pulmonary Hypertension
• Association with Severe OSA and CAD• Cause or effect??
• Clear studies that OSA worsens CHF
OSA And Arrhythmia
• Unclear cause vs. effect relationship
• >30 events/hour, pts had increase in:• Nocturnal Atrial Fibrilation• Nonstustained nocturnal VTACH
• In patients with AFIB and Untreated OSA, AFIB is more likely to reoccur after cardioversion• 82% vs. 42%
What to do about it?
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