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.

• • • • • • 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 • CCB’s • 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

– In unstable patients, do as soon as practicable – Chemical cardioversion
• Some drugs shown to be effective • Dofetilide, flecainide, ibutilide, propafenone, amiodarone • Problems with pro-arrythmic characteristics

Approaches to Maintenance of NSR
• Antiarrythmics
– Only used when significant side effects on rate control – Drugs most commonly used
• Amiodarone, propafenone, disopyramide, sotalol, flecainide, and quinidine • Amiodarone may be the most effective but has significant side effects

• Cardioversion as needed

• •

Maintenance of Rate Control May be the optimal therapy
– Rest heart rate 80 beats/min – 24-hour Holter average 100 beats/min and no heart rate >110 percent of the age-predicted maximum – Heart rate 110 beats/min in six minute walk

Reasons to avoid high rates in chronic AF
– Avoidance of hemodynamic instability and/or symptoms such as palpitations, heart failure, angina, lightheadedness, and poor exercise capacity – Over the long-term, avoidance of a tachycardia-mediated cardiomyopathy

– 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
– 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

• Rhythm control preferable if:
– Significant symptoms on rate control – Inability to obtain rate control – Patient preference

• 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

– 4 weeks is not required if onset less than 48 hours
• Controversial whether or not to anticoagulate after cardioversion, consensus is 4 weeks • Some authorities use ASA after first episode and warfarin thereafter

Anticoagulation for Paroxysmal and Chronic AF
• CHADS score is well-validated test for decision as to type of anticoagulation (next slide)
– Patients with a CHADS2 score of 0 are at low risk for ischemic stroke or peripheral embolization (0.5 percent per year in the absence of warfarin) and can be managed with aspirin – Patients with a CHADS2 score 3 are at high risk (5.3 to 6.9 percent per year) and should, in the absence of a contraindication, be treated with warfarin – Patients with a CHADS2 score of 1 or 2 are at intermediate risk (1.5 to 2.5 percent per year). In this group, the choice between warfarin therapy and aspirin will depend upon many factors, including patient preference

• INR of 2.0-3.0 if warfarin used

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

Indications for emergent cardioversion
– Active ischemia – Significant hypotension, to which poor LV systolic function, diastolic dysfunction, or associated mitral or aortic valve disease may contribute – Severe manifestations of HF – The presence of a preexcitation syndrome, which may lead to an extremely rapid ventricular rate

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

• Higher risk features in which there is a higher risk of mortality
– Older age – Coexisting CV disease – Women