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Atrial Fibrillation: October 10, 2005 MLK Clinic Lecture Series
Atrial Fibrillation: October 10, 2005 MLK Clinic Lecture Series
Atrial Fibrillation
Classification of A Fib
Paroxysmal (ie, self-terminating). AF in which the episodes of AF generally last less than seven days (usually less than 24 hours) and may be recurrent. Persistent AF fails to self-terminate and lasts for longer than seven days. Persistent AF may also be paroxysmal if it recurs after reversion. AF is considered recurrent when the patient experiences two or more episodes. Permanent AF is considered to be present if the arrhythmia lasts for more than one year and cardioversion either has not been attempted or has failed. "Lone" AF describes paroxysmal, persistent, or permanent AF in individuals without structural heart disease.
EVALUATION
History and physical examination Electrocardiogram CXR Echocardiogram Evaluation for hyperthyroidism Other
Evaluation for CAD Holter monitoring for other arrythmias EPS studies
Treatment Principles
Rate control vs rhythm control
Rate control generally recommended
Beta blockers CCBs Digoxin not effective during exercise
Anticoagulation
Wafarin recommended ECASA if benefit of warfarin not clear
Rhythm control
Cardioversion EPS Antiarrythmics not recommended since higher risk of mortality
Rhythm Control
Cardioversion
Timing
If >48 hours since onset of AF, anticoagulate for 3-4 weeks prior to electrical cardioversion May do TEE, if no thrombi, may anticoagulate for shorter period
Cardioversion as needed
Drugs
Slow AV nodal conduction with a beta blocker, diltiazem, verapamil Patients with heart failure or hypotension, digoxin Amiodarone is also effective, although it is not used as a primary therapy for rate control
Rate control vs rhythm control AFFIRM and RACE trials showed superiority of rate
control
Embolic events occur with equal frequency regardless of whether a rate control or rhythm control strategy is pursued, and occur most often after warfarin has been stopped or when the INR is subtherapeutic Both studies showed an almost significant trend toward a lower incidence of the primary end point with rate control hazard ratio 0.87 for mortality in AFFIRM and 0.73 for a composite end point in RACE There was no difference in functional status or quality of life
Anticoagulation
Cardioversion
If after 48 hours of onset, unknown onset, recent thromboembolism or mitral stenosis
4 weeks of anticoagulation first At least 4 weeks of anticoagulation after cardioversion, but preference is for chronic anticoagulation Target INR 2.5 Alternative is TEE first without anticoagulation
Management of AF in ER
New onset AF is usually reason for admission although in lower risk patients may treat as outpatient. Reasons for admission
For the treatment of an associated medical problem, which is often the reason for the arrhythmia For elderly patients who are more safely treated for AF in hospital For patients with underlying heart disease who have hemodynamic consequences from the AF or who are at risk for a complication resulting from therapy of the arrhythmia
Rate control
Digoxin is preferred only if HF Otherwise CCB or beta blocker is preferred
Subsequent Management
Long-term Outcome
Prognosis is good in lone afib
Younger patients No other coexisting morbidities