Dr Yeo Wee Tiong

MBBS, MMed(Int Med), MRCP(UK), ECES, ECDS

Consultant Cardiologist and Electrophysiologist
}  Most common arrhythmia
}  AF affects 1–2% of the population
}  US: 3.8-8.9 million in 2025
}  US: 5.6-15.9 million in 2050
}  Age standardized prevalence increasing
Naccarelli et al. Am J Cardiol 2009;104:1534–1539
}  Occurs in ~0.5–1% of general population1
}  Overall Singapore prevalence of 1.5%
}  (Singapore Longitudinal Aging Study)2
◦  2.6% in males vs. 0.6% in females >55 yrs
◦  5.8% for those > 80yrs
}  Majority (> 90%) of AF are of nonvalvular

1. MOH CPG 8/2004 Management of Atrial fibrillation

2. Yap KB et al. Journal of Electrocardiology 41 (2008) 94–98
 Substrate Trigger

Atrial fibrillation
Heart failure

Ischemic heart
disease

Mitral valve
disorders

Congenital
heart disease
}  Aging
}  Hypertension
}  Heart failure
}  Mitral valve disorders
}  Other structural heart disease
}  Hyperthyroidism
}  Lung disease
}  Obesity
}  Sleep apnoea
}  Diabetes mellitus
}  Alcohol use
ê Quality of life
Mechanisms underlying atrial fibrillation (AF)–related thromboembolism. vWF indicates von
Willebrand factor; NOS, nitric oxide synthase; TF, tissue factor; TFPI, tissue factor pathway
inhibitor; TM, thrombomodulin; TNFα, tumor necrosis factor-α; VEGF, vascu...

Iwasaki Y et al. Circulation 2011;124:2264-2274

Copyright © American Heart Association

Schneck M, Lei X. Cardioembolic stroke. eMedicine Neurology 2008. http://
emedicine.medscape.com/ article/1160370-overview. Accessed March 2009
Jørgensen HS et With AF Without AF Univariate P
al.Stroke. 1996;27:1765-1769
Initial stroke severity 29.7±17.0 37.5±17.0 <.0001

Initial disability (Barthel Index) 34.5±39.1 51.7±41.3 <.0001

Length of hospital stay, d 50.4±49.9 39.8±44.6 <.001

In-hospital mortality, n (%) 72 (33) 171 (17) <.00001

Discharged to nursing home, n (%) 41 (19) 135 (14) .06

Discharged to own home, n (%) 104 (48) 662 (69) <.00001

Neurological outcome 46.3±14.3 49.8±12.2 .003

Functional outcome 66.8±38.0 78.0±32.8 .0007

Framingham heart study
Relevance?

•  Symptom severity

•  Likelihood of staying in
sinus rhythm
AF = atrial fibrillation
}  ECG
◦  LVH
◦  Q waves
◦  Pre-excitation
◦  HR and regularity
 Atrial
Fibrillation
}  Echocardiography
◦  Valvular heart disease
◦  Left ventricular hypertrophy
◦  Ejection fraction
◦  Left atrial size
◦  Any structural heart disease
}  Holter study
◦  Suspected AF
◦  Rate control
◦  Pauses
}  Electrolytes, urea, creatinine
}  FBC
}  Thyroid function

}  Fasting glucose
}  Lung function (if significant respiratory
history)
AF= atrial fibrillation; EF = ejection fraction (as documented by echocardiography, radionuclide ventriculography, cardiac
catheterization, cardiac magnetic resonance imaging, etc.); LV = left ventricular; TIA = transient ischaemic attack.
*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary
cohorts may vary from these estimates.
Paroxysmal
Persistent
Permanent
Does not matter!!
*Hypertension is defined as systolic blood pressure > 160 mmHg.
INR = international normalized ratio.
Warfarin failure Prosthetic valves
Unable to maintain INR
Stroke despite warfarin
GFR<30
Cost
}  >90% of left atrial
thrombi found in
atrial appendage

}  Indications
◦  Anticoagulation
failure
◦  Contraindications for
anticoagulation
THINK ANTICOAGULATION!!
Onset<48 hours
Heparin before then anticoagulate if CHA2DS2VASc
score is high

Onset >48hours
Anticoagulate 3 weeks before and then for 4 weeks
after
Or
Transesophageal echocardiography before and
then anticoagulate for 4 weeks after

Anticoagulation beyond 4 weeks determined by

CHA2DS2VASc score
}  Atrial fibrillation: Biphasic 200J
}  Atrial flutter: Biphasic 100J
Remember to SYNC!

Press and hold shock button

till shock delivered

2 3
}  Rate control }  Rhythm control

X
X

◦  AV node blocking
agents ◦  Maintain sinus rhythm
–  Beta blockers –  Pharmacologic
–  Non dihydropyridine –  Electrical cardioversion
calcium channel blockers –  Ablation
–  Digoxin
◦  AVN ablation and
pacemaker
}  AFFIRM and RACE trials
◦  No difference between the 2 groups in terms of cumulative
mortality and serious events
◦  Improvement in quality of life scores but no difference in
the 2 groups
◦  Rate of adverse events lower in the rate control group
◦  Rate control strategy was more cost effective

}  STAF and PIAF (pilot trials)

◦  Similar results

}  Caveats
◦  Toxicity of rhythm control drugs may have reduced the
difference in outcomes
◦  Studies pre-date catheter ablation
}  Both strategies reasonable
◦  Rate control
–  Older, few symptoms
◦  Rhythm control
–  Young, active
–  Symptoms despite rate control
 EF<40%

Amiodarone
1.  Treatment is motivated by attempts to reduce AF-related

symptoms.
2.  Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest.
3.  Clinically successful antiarrhythmic drug therapy may reduce
rather than eliminate recurrence of AF.
4.  If one antiarrhythmic drug ‘fails’ a clinically acceptable response

may be achieved with another agent.
5.  Drug-induced proarrhythmia or extra-cardiac side-effects are

frequent.
6.  Safety rather than efficacy considerations should primarily guide

the choice of antiarrhythmic agent.
100

65
Amiodarone
50%
37 Sotalol or
SR Propafenone

AFFIRM, Denis R et al NEJM 2000