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Atrial Fibrillation

October 10, 2005


MLK Clinic Lecture Series
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
• 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
• Goals
– 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
• 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
• Rhythm control preferable if:
– Significant symptoms on rate control
– Inability to obtain rate control
– Patient preference
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
– 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