Atrial Fibrillation

Lauren Goeser, PGY-1 Pharmacy Resident

lgoeser@iuhealth.org
Normal Sinus Rhythm and Arrhythmias
 Heart rate (HR) describes the frequency of depolarization of the ventricles
⎻Normal HR in normal sinus rhythm (NSR) is 60 - 100 BPM
 The rate and rhythm is set by the rapidly firing cells in the SA node called the
heart’s natural pacemaker
 An arrhythmia is caused by a disruption somewhere in the conduction system:
⎻SA node can be firing at an abnormal rate or rhythm
⎻Scar tissue from a prior heart attack can block and divert signal transmission
⎻Another part of the heart may be acting as the pacemaker

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Etiologies of Arrhythmias
 Electrolyte imbalances: potassium, magnesium, sodium, calcium
 Elevated sympathetic states: hyperthyroidism, infection
 Drugs: illicit drugs, anti-arrhythmics (from abnormal levels)
 Myocardial ischemia
 Hypertension and heart failure

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Types of Atrial Fibrillation
Type Definition
Paroxysmal Terminates with intervention or spontaneously within 7 days
Persistent Continuous and sustained > 7 days
Long-standing Continuous and sustained > 12 month
persistent
Permanent Clinician and patient decide to stop attempting to restore and maintain
NSR
Valvular With mechanical heart value or moderate to severe mitral stenosis
Non-valvular Without mechanical heart value or moderate to severe mitral stenosis

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Patient Case

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Signs and Symptoms
 Palpitations
 Fatigue
 Shortness of breath
 Hypotension
 Dizziness
 Lightheadedness
 Syncope

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Treatment

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Patient Case

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 Rhythm
Rate Control Cardioversion
Control
• Beta • Class Ia
blockers • Class Ic
• Non-DHP • Class III
CCBs
• Digoxin

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 A Comparison of Rate Control and
Rhythm Control in Patients with
Atrial Fibrillation

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Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg , Y., Schron, E. B., Atrial Fibrillation Follow-up Investigation of Rhythm Management, I. (2002). A
comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med, 347(23), 1825-1833. doi:10.1056/NEJMoa02138
 A Comparison of Rate Control and Rhythm Control in Patients
with Atrial Fibrillation
 Objective: the difference in overall mortality in patients with atrial fibrillation treated with rate
control versus rhythm control
 Methods: randomized, multicenter comparison of 4060 patients
 Treatment:
 Rhythm control: chosen by provider, amiodarone, disopyramide, flecinide, moricizine,
procainamide, proprafenone, quinidine, sotalol; included cardioversion as necessary
 Rate control: goal heart rate 80 bpm at rest and 110 bpm during six-minute walk test, beta
blockers (diltiazem, verapamil), digoxin

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Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg , Y., Schron, E. B., Atrial Fibrillation Follow-up Investigation of Rhythm Management, I. (2002).
A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med, 347(23), 1825-1833. doi:10.1056/NEJMoa02138
 A Comparison of Rate Control and Rhythm Control in Patients
with Atrial Fibrillation
 Patient population: ≥ 65 years old or who had other risk factors for stroke or death and had atrial
fibrillation that was likely to be recurrent, atrial fibrillation that was likely to be the cause of
illness or death, long-term treatment for atrial fibrillation was warranted, and anticoagulant
therapy was not contraindicated
 Results:
 Mortality at five years: 23.8% in the rhythm control group and 21.3% in the rate control group
 More patients hospitalized in the rhythm control group
 More adverse drug effects occurred in the rhythm control group
 Conclusion: rhythm control does not offer a survival advantage over rate control and could lead
to increased adverse drug effects

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Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg , Y., Schron, E. B., Atrial Fibrillation Follow-up Investigation of Rhythm Management, I.
(2002). A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med, 347(23), 1825-1833. doi:10.1056/NEJMoa02138
Anticoagulation

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Patient Case

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Patient Case

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Preferred Anticoagulant
 Non-Valvular atrial fibrillation: DOACs
 Mechanical heart valves: warfarin

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 Efficacy and Safety of Apixaban vs
Warfarin in Patients with Atrial
Fibrillation and Prior Bioprosthetic
Valve Replacement or Valve Repair

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Guimaraes, P. O., Pokorney, S. D., Lopes, R. D., Wojdyla, D. M., Gersh, B. J., Giczewka., Granger, C. B. (2019). Efficacy and safety of apixaban vs warfarin in patients with atrial
fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial. Clin Cardiol, 42(5), 568-571. doi:10.1002/clc.23178
 Efficacy and Safety of Apixaban vs Warfarin in Patients with Atrial
Fibrillation and Prior Bioprosthetic Valve Replacement or Valve
Repair
 Objective: to evaluate the efficacy and safety of apixaban versus warfarin the patients with atrial
fibrillation and a history of bioprosthetic valve replacement or valve replacement
 Methods: used data from the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other
Thromboembolic Events in Atrial Fibrillation) and contacted site to obtain information about
prior valve surgery
 ARISTOTLE: randomized control trial comparing apixaban with warfarin in patients with
atrial fibrillation, included patients with valve replacements

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Guimaraes, P. O., Pokorney, S. D., Lopes, R. D., Wojdyla, D. M., Gersh, B. J., Giczewka., Granger, C. B. (2019). Efficacy and safety of apixaban vs warfarin in patients with
atrial fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial. Clin Cardiol, 42(5), 568-571. doi:10.1002/clc.23178
 Efficacy and Safety of Apixaban vs Warfarin in Patients with Atrial
Fibrillation and Prior Bioprosthetic Valve Replacement or Valve
Repair
 Patient population: 104 patients (0.6%) in the ARISTOTLE trial had a history of bioprosthetic
valve (BPV) and 52 (0.3%) had a history of native valve repair
 BPVs: 55 received apixaban and 49 received warfarin
 Native valve repair: 32 received apixaban and 20 received warfarin
 Results:
 Stroke: 2.77% patients in apixaban group vs. 1.64% in warfarin group (p = 0.53)
 All-cause death: 4.61% patients in apixaban group vs. 4.79% in warfarin group (p = 0.98)
 Major bleeding: 5.87% patients in apixaban group vs. 6.44% patient in warfarin group (p =
0.82)
 Conclusion: the safety and efficacy of apixaban was comparable to warfarin but larger
randomized controlled trials should be performed to definitely assess the efficacy and safety
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Guimaraes, P. O., Pokorney, S. D., Lopes, R. D., Wojdyla, D. M., Gersh, B. J., Giczewka., Granger, C. B. (2019). Efficacy and safety of apixaban vs warfarin in patients with
atrial fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial. Clin Cardiol, 42(5), 568-571. doi:10.1002/clc.23178
Anticoagulation
 Apixaban (Eliquis): 5mg PO BID
⎻If patient has  2: age  80, body weight  60kg, SCr  1.5mg/dl  2.5mg BID
 Rivaroxaban (Xarelto): 20mg PO daily with evening meal
⎻If CrCl 15 - 50ml/min  15mg PO daily
 Dabigatran (Pradaxa): 150mg PO BID
⎻If CrCl 15 – 30ml/min  75mg BID
 Edoxaban (Savaysa): 60mg daily
⎻If CrCl 15 – 50ml/min  30mg daily
⎻Contraindicated if CrCl > 95ml/min or < 15ml/min

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References
 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients
with Atrial Fibrillation. J Am Coll Cardiol. 2019; doi.org/10.1016/j.jacc.2019.01.011.
 Shapiro K, Brown S. Chapter 32. Arrhythmias. In: RxPrep Course Book. 2020 ed. RxPrep, Inc; 2020.
 Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg , Y., Schron, E. B., Atrial Fibrillation
Follow-up Investigation of Rhythm Management, I. (2002). A comparison of rate control and rhythm control in
patients with atrial fibrillation. N Engl J Med, 347(23), 1825-1833. doi:10.1056/NEJMoa02138.
 Guimaraes, P. O., Pokorney, S. D., Lopes, R. D., Wojdyla, D. M., Gersh, B. J., Giczewka., Granger, C. B. (2019).
Efficacy and safety of apixaban vs warfarin in patients with atrial fibrillation and prior bioprosthetic valve
replacement or valve repair: Insights from the ARISTOTLE trial. Clin Cardiol, 42(5), 568-571.
doi:10.1002/clc.23178.

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Atrial Fibrillation
Lauren Goeser, PGY-1 Pharmacy Resident
lgoeser@iuhealth.org