Management of Atrial Fibrillation

Causes of Atrial Fibrillation

Cardiac Valvular dz MR, MS IHD HPT Post MI CCF ASD Cardiomyopathy Hyperthyroidism Sepsis esp pneumonia Sick sinus syndrome Post-cardiac surgery Peri-/myo-carditis Pre-excitation syndrome Acute pul. Embolism Lone AF (no known etiology or structural heart dz. Dx of exclusion) DM Alcohol

Assess the need to convert to sinus rhythm

Physical Exam
confirm AF (4 signs) o IR IR pulse o Single flicker JVP - absence of a wave o pulse deficit o varying loudness of 1st heart sound signs of underlying causes of AF BP, goiter and signs of thyrotoxicosis, auscultation for murmurs (MR/MS) complications CCF, previous stroke

Non-Cardiac

Investigations
ECG CXR FBC U/E TFT Transthoracic echocardiogram (TTE) Additional Invxs 24h Holter to document AF, any evidence of MI, LVH/LAH chamber size, heart failure hyperthyroidism structural HD (CMP, valvular dz, intracardiac shunt, pericardial HDz), chamber sizes LV size and function. Quantify freq & duration of symptomatic & asymp. AF episodes Look for sinus node dysf(x) or sick sinus syndrome Assess adequacy of rhythm or rate control Assess time of onset of AF (eg night in vagally-mediated AF) Identify PTs with frequent atrial ectopics & nonsustained atrial tachycardia suitable for catheter ablation Gives better visualization of LA thrombus cf TTE) Use before elective cardioversion in PTs w/o prior 3wks warfarin Assess PT with AF ppted by exertion, IHD or MI Routinely done for PTs 40YO or with significant coronary risk factors. For PTs w hx of syncope to exclude sick sinus syndrome and Wolff-Parkinson-White syndrome

Morbidities of AF
cardiac output malaise and effort intolerance aggravation of MI and heart failure risk of Thromboembolism and stroke

Types of AF:
1st detected episode - may not need tx if episode is brief/ known reversible cause Acute AF detected within 24-48h, has high chance of pharm/electrical cardioversion Paroxysmal AF AF lasting less than 7 days Persistent AF >7 days Permanent AF previous attempts to restore sinus rhythm have failed/ AF lasted >1y. The probability of successful cardioversion is very low

Clinical Presentations
Palpitations CP Dyspnoea Fatigue Light headedness Syncope Cxs of AF heart failure, haemodynamic impairments, stroke Asymptomatic (25%) Transesophageal echocardiogram (TEE) Exercise stress test

Electrophysiological study (EPS)

Evaluation of AF
stable or unstable confirm diagnosis of AF with 12 lead ECG classify type of AF determine underlying cause/factors contributing to AF (eg structural and ischaemic HDz, estimating LVEF, valvular HDz, CMP, HPT) look for complications of AF determine risk of future complications, i.e. stroke, from AF o HTN/ old age/ IHD/ heart failure / previous stroke/ DM Assess adequacy of control of ventricular rate during AF

Management of AF:
Aims: o o o Control ventricular rate Reestablish sinus rhythm Anticoagulate to prevent Thromboembolism Improve symptoms Reduce TE stroke risk Prevent cardiac remodeling and hence HFailure & CMP

Unstable:
o o immediate sync. Cardioversion f/u with anticoagulation therapy for 4 weeks

Stable: a) Acute AF (<48h)

Can be cardioverted (pharm/electrical) without prior long-term anticoagulation Give IV heparin before proceeding And switch to oral, maintain INR at 2-3 for 4 weeks whatever the outcome

Rhythm Control:
Spontaneous cardioversion occurs in 50-70% of PTs w/in 24 to 48 hrs, but unlikely to occur if AF persisted for > a week. Drug/electrical cardioversion will be necessary. Success rate of cardioversion decrease as duration of AF increase, therefore perform early Problems: failure in maintenance of sinus rhythm in >50% of PTs, significant SE of drugs used Pharmacological Cardioversion: Drug Comments Class IC arrhythmics Contraindications (propafenone 300- IHD 600mg PO stat, - CCF flecainide150-200mg - Lt vent dysf(x) PO stat) - major conduction disturbances Amiodarone Takes days to wks for onset (600-800mg/day PO) Safe for PT with structural heart dz or heart failure Monitor LFT & TFT 6 mthly for SE

b) Persistent/ Recurrent Paroxysmal AF

If minimal symptoms, 1) Rate control o Beta-blocker o Ca blockers e.g. diltiazem/ verapamil o Digoxin (esp if concurrent HF) o Sotalol 2) Assess for risk of thromboembolism and anticoagulate as necessary This is the recommended management for most patients, unless acute onset (<48h), or symptomatic, or complicated

SE conversion to atrial flutter ventricular tachycardia enhanced AV nodal conduction CCF Hepatotoxic Thyroid dysfunction GI upset Bradycardia Torsades de pointes polyneuropathy Hypotension Torsades de pointes Torsades de pointes CCF Exacerbation of COPD

c) Symptoms/ complications (e.g. syncope, heart failure, stroke)

Rate control initially followed by cardioversion, with anticoagulation Then, o anticoagulate for 3 weeks with warfarin (keep INR 2-3) before cardioversion Amiodarone Flecainide Propafenone o Alternatively, do TEE to look for LA thrombus. If none, give IV Heparin and perform DC cardioversion w/o prior anticoagulation. Post cardioversion, maintain INR at 2-3 for 4 weeks Maintenance of sinus rhythm (Flecainide, propafenone, sotalol, amiodarone) AF Unstable Sync cardioversion 4 wks anticoagulation
st

Dofetilide & ibutilide Quinidine Sotalol NOT for cardioversion Only for maintaining sinus rhythm

Stable

Electrical cardioversion: o PT must be fasted and sedated, with good IV access and airway Mx o Check electrolyte and anticoagulation status Monophasic AF 200 joules, increments up to 360 joules Atrial flutter 50 joules Biphasic AF 100 joules initially o Cxs: Thromboembolism, arrhythmia, myocardial injury, heart failure, skin burns. Other non-pharmacological rate control therapies o Permanent Pacing o Catheter ablation for PTs with paroxysmal AF due to atrial ectopics, PT with SVT or atrial flutter o Surgical ablation Maze procedure: consider concomitant Sx ablation in PTs going for open heart Sx for valvular, ischaemic or congenital heart dz. Maintenance of Sinus Rhythm o Flecainide, propafenone and sotalol are first line drugs o Amiodarone superior to previous drugs, but last choice of drug due to long term extracardiac SE.

1 episode / Acute AF (<48hrs) Pharm / electrical cardioversion w/o prior anticoagulation 4 wks anticoagulation long-term anticoagulation not necessary Asymptomatic Rate control Long-term anticoagulation

Persistant / recurrent paroxysmal AF

Symptomatic / complicated Rate control & anticoagulation Cardioversion & maintain sinus rhythm Long term anticoagulation

Treat ppt factor if present Failure of drug therapy to achieve rate control or maintain sinus rhythm consider pacemakers, defibrillator or catheter ablation

Choice of drug in heart dz: Heart failure: use amiodarone CAD: use sotalol HPT with LVH 1.4cm: use amiodarone

Contraindications to anticoagulation Significant bleeding or fall risk Recent surgery / trauma Thrombocytopenia Antithrombotic strategies Any high-risk factors present >60YO with one other moderate risk factor <60YO + one moderate risk factor 60-75YO with no risk factor Male >75 with no risk factor Low risk or warfarin is CI

PT unlikely to comply with diet & monitoring regimen Active peptic ulcer dz

Rate Control:
Similar efficacy to rhythm control, but drugs used are safer and there is no problems wrt maintenance of sinus rhythm Pharmacological rate control: Drug Comments SE First line Rx Bronchoconstriction. CI in -blockers asthma (propranolol, atenolol, Caution in PTs with heart sotalol) failure Heart failure Hypotension Heart block Bradycardia CCB (verapamil, IV CCB useful in Hypotension diltiazem) emergencies Heart block Preferred over -blockers Heart failure in PT with COPD Caution in PTs with heart failure Digoxin Good for PT with heart Digitalis toxicity failure Heart block Caution in elderly and PT Bradycardia with renal dysf(x) Amiodarone Good for PT with heart Thyroid dysfunction failure Hepatotoxicity Not first line due to SEs Torsades de pointes require monitoring of LFT Warfarin & digoxin and TFT interaction *combination therapies are possible eg digoxin & -blockers Non-pharmacological rate control: Permanent pacing AV nodal ablation & permanent pacing:

Long-term oral anticoagulation (target INR2.5; range 2.0-3.0) Either aspirin 100mg/day or warfarin depending on PT preference, risk of blding and access to anticoagulation monitoring Aspirin (100-300mg/day). Alternatives: ticlopidine, clopidogrel, dipyridamole Long term aspirin or no Rx

<60YO with no risk factors & normal left atrial size *always consider PT factors in determining target INR level (eg fall risk in elderly, recurrent TE events despite anticoagulation, prosthetic heart valves) & modify Rx accordingly Monitoring: wkly INR initially, then 6-8wkly once INR stabilizes. Adjustment of warfarin dose: o after change in drugs that interact with warfarin (eg amiodarone) o surgery (stop warfarin for 5 days prior to surgery)

Anticoagulation:
Prevent thromboembolic Cxs eg stroke & peripheral arterial thromboembolism Risk factors High risk factors Prior stroke/ TIA/ systemic embolism Prosthetic heart valve Rheumatic mitral stenosis >75YO Moderate risk factors 60-75YO LVEF 35% HPT DM CCF Thyrotoxicosis Coronary artery dz Low risk factors <60YO

Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KTCampus, Terengganu, ou=Internal Medicine Group, email=wunna.hlashwe@gmail.com Reason: This document is for UCSI year 4 students. Date: 2009.02.24 10:15:03 +08'00'