Atrial Fibrillation and Atrial Flutter Jimmy Asaf

Atrial Fibrillation and Atrial Flutter
Jimmy Oi Santoso
M. Fajri Addai
Resource Person :
Prof. Dr. dr. Yoga Yuniadi, SpJP(K)
Atrial fibrillation - Definition
• A supraventricular tachyarrhythmia with uncoordinated atrial
electrical activation and consequently ineffective atrial contraction.
• Electrocardiographic characteristics of AF include:
• Irregularly irregular R-R intervals (when atrioventricular conduction is not
impaired,) or more regular in high degree AV block
• Usually, fast atrial fibrillatory rate (300-600 bpm) and variable ventricular
response (usually 100-160 bpm in untreated pts)
• Absence of distinct repeating P waves, and
• Irregular atrial activations
ESC AF guidelines 2020

Braunwald’s heart disease, 2019
Epidemiology
● Prevalence 2-4% in adults
● MONICA study : 0,2% in adult
population in Jakarta
● Harapan Kita : 7,1% (2010) 
9,8% (2013)
● Lifetime risk for AF (1 in 3 www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
individuals) (European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
Figure 2 (2)
● More common in male , risk Epidemiology
increases over time (older lifetime risk a
projected rise
age=risk>>>) incidence and
● Risk increased with various prevalence
disease such as CKD, HF, CAD,
OSA, obesity, dst
a Smoking, alcohol consumption
diabetes mellitus (type 1 or 2), a
Braunwald’s heart disease, 2019 infarction or heart failure. bRisk
factors are negative or within th
Buku Ajar Kardiovaskular FKUI, 2017 no elevated risk factors but >1 b
elevated − >1 elevated risk facto
Epidemiology
 AF results causes increased
risk in several AF related
outcomes
 AF is independently
associated with a 2x
increased risk of all-cause
mortality in women and a
1.5x increase in men
 AF is found in 20-30% pts
with ischemic stroke

Risk Factors
AF Risk Factors
Non Modfiable
Age
CV Outcomes
Genetic
Gender Stroke
Ethnicity CHF
Modifiable MI
Physical Activity SEE
Smoking Dementia
Obesity VTE
OSA
Hypertension
Metabolic syndrome
CV insults
MI
HF

Atrial Fibrillation Mechanism
Iwasaki et al. Circulation. 2011

Focal Mechanism
• Source of focal ectopic impuls:

1. 72% from Pulmonary Vein
2. 28% : SVC (37%), posterior wall of LA (38,3%), crista
terminalis (3,7%), coronary sinus (1,4%), ligamentum
Marshall (8,2%), and inter-atrial septum

Diagnosis
Clinical Features
• Anamnesis :
• Variable clinical presentation
• 50% asymptomatic, palpitation, irregular heart beat, dyspnea,
syncope/presyncope (in diastolic dysfunction/sick sinus), thromboembolic
symptoms, polyuria (atrial stretch  ANP)
• Physical examination :
• Vital sign (stable or unstable), exophthalmos, thyroid disease, carotid artery
bruit, barrel chest or accentuated P2, cardiac murmur
• Further diagnostic studies :
• ECG, TTE, TEE, liver and renal function, thyroid, electrolytes, routine blood test,
cardiac enzyme, BNP, ANP
Buku ajar kardiologi FKUI, 2017
Anamnesis
Diagnostic Workup
Clinical Types of AF
AF screening
● Asymptomatic clinical AF independently associated with increased risk of
stroke and mortality compared with symptomatic AF
● Screen-detected AF responds to treatment similarly to AF detected by
routine care according to observational studies
● Advances in technology enables easy, and personal detection of AF
episodes
● However, data regarding health benefits and optimal screening strategy is
scare
Sensitivity and Specificity of AF screening tools compared to 12-lead ECG
Method Sensitivity Specificity
Pulse taking 87-97% 70-81%
Automated BP monitor 93-100% 86-92%
Single lead ECG 94-98% 76-95%
Smartphone apps 91.5-98.5 91.4-100%
Watches 97-99% 83-94%

Management
©ESC
● Stroke risk assessment - CHA2DS2-VASc
Anticoagulation/Avoid
A Stroke
● Bleeding risk assessment
● Stroke prevention therapies
● Rate Control
B Better Symptom Control ● Rhythm Control
Cardiovascular Risk Factors and ● Lifestyle Intervention

C Concomitant Disease: detection ● Specific cardiovascular risk factors/comorbidities
and management
Recommendations for the prevention of thromboembolic
events in AF (1)
Recommendations Class Level

For stroke prevention in AF patients who are eligible for OAC, NOACs are
recommended in preference to VKAs (excluding patients with mechanical I A
heart valves or moderate-to-severe mitral stenosis).
For stroke risk assessment, a risk-factor−based approach is recommended,
using the CHA2DS2-VASc clinical stroke risk score to initially identify patients
I A
at ‘low stroke risk’ (CHA2DS2-VASc score = 0 in men, or 1 in women) who
should not be offered antithrombotic therapy.
OAC is recommended for stroke prevention in AF patients with CHA 2DS2-
I A
VASc score ≥2 in men or ≥3 in women.
©ESC
www.escardio.org/guidelines 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation
(European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)
events in AF (2)

OAC should be considered for stroke prevention in AF patients with a CHA2DS2-VASc
score of 1 in men or 2 in women. Treatment should be individualized based on net IIa B
clinical benefit and consideration of patient values and preferences.
For bleeding risk assessment, a formal structured risk-score−based bleeding risk
assessment is recommended to help identify non-modifiable and address
modifiable bleeding risk factors in all AF patients, and to identify patients I B
potentially at high risk of bleeding who should be scheduled for early and more
frequent clinical review and follow-up.
For a formal risk-score−based assessment of bleeding risk, the HAS-BLED score
should be considered to help address modifiable bleeding risk factors, and to IIa B
identify patients at high risk of bleeding (HAS-BLED score ≥3) for early and more
©ESC
frequent clinical review and follow-up.
events in AF (3)
Stroke and bleeding risk reassessment at periodic intervals is recommended
to inform treatment decisions (e.g. initiation of OAC in patients no longer at I B
low risk of stroke) and address potentially modifiable bleeding risk factors.a
In patients with AF initially at low risk of stroke, first reassessment of stroke
IIa B
risk should be made at 4−6 months after the index evaluation.
If a VKA is used, a target INR of 2.0−3.0 is recommended, with individual
I B
TTR ≥70%.
aIncluding uncontrolled BP; labile INRs (in a patient taking VKA); alcohol excess; concomitant use of NSAIDs or aspirin in an anticoagulated patient; bleeding tendency or
predisposition (e.g. treat gastric ulcer, optimize renal or liver function etc.).
©ESC
events in AF (4)
In patients on VKAs with low time in INR therapeutic range (e.g. TTR <70%),
recommended options are:
I B
• Switching to a NOAC but ensuring good adherence and persistence with
therapy; or
• Efforts to improve TTR (e.g. education/counselling and more frequent INR
IIa B
checks).
Antiplatelet therapy alone (monotherapy or aspirin in combination with
III A
clopidogrel) is not recommended for stroke prevention in AF.
Estimated bleeding risk, in the absence of absolute contraindications to OAC,
III A
should not in itself guide treatment decisions to use OAC for stroke prevention.
Clinical pattern of AF (i.e. first detected, paroxysmal, persistent, long-standing persistent,
III B
©ESC
permanent) should not condition the indication to thromboprophylaxis.
events in AF (5)
Recommendations for occlusion or exclusion of the LAA Class Level
LAA occlusion may be considered for stroke prevention in patients with AF
and contraindications for long-term anticoagulant treatment (e.g. intracranial IIb B
bleeding without a reversible cause).
Surgical occlusion or exclusion of the LAA may be considered for stroke
IIb C
prevention in patients with AF undergoing cardiac surgery.
©ESC
Vitamin K antagonist
Warfarin or brand name Coumadin initially used as rat
poison.
Reduces stroke risk by 64% and mortality by 26%
Initial dose: 2 to 5 mg orally once a day
Maintenance dose: 2 to 10 mg orally once a day
Target
INR: 2.5 (range: 2 to 3)
Dosing may be modified in Asians with CYP2C9 genetic
variation, hepatic impairment and certain dietary patterns
Contraindicated in patients with severe bleeding epidsode
Braunwald heart disease, 2019

Non-vitamin K antagonist oral anticoagulants
Dabigatran RE-LY
Rivaroxaban ROCKET-AF
More effective and

Rivaroxaban J ROCKET-AF safer in Asians
Apixaban ARISTOTLE
ENGAGE AF
Edoxaban TIMI
Meta analysis Wang KL et al. 2015
ESC guidelines AF 2020
NOAC vs VKA

LAA Occluder Devices

Figure 22 Management of active bleeding in patients receiving
anticoagulation
©ESC
Management of active bleeding in patients receiving anticoagulation (institutions should have an agreed procedure in place).
A Stroke
● Rate Control

and management

Better Symptom Control - Rate Control
● HR target : no
difference in strict and
lenient HR target (RACE,
RACE-II, AFFIRM)

AV node ablation and Pacing
● If rate and rhyhthm control fails, AV node ablation and
pacing should be considered esp. in older age 
consider irreversibility of the procedure
● In permanent AF with history of hospitalization of HF,
AVN ablation + CRT may be preferred (small RCT 
less mortality and morbidity)
● Choice of pacing (RV/biventricular/His Bundle)
depends of patient characteristics
ESC guidelines AF
2020
A Stroke
● Rate Control

and management

Rhythm Control Strategies
●Cardioversion
○Electrical: Choice in hemodynamically unstable patients.
Synchronized biphasic defibrillators superior to
monophasic, & must be done under sedation
○Pharmacological: Done usually hemodynamically stable,
new onset AF patients. Multiple drug options including
‘pill in the pocket’ approach
●Ablation
Rate vs Rhythm Control
Pedoman AF PERKI 2014

Indications of Catheter Ablation in symptomatic AF
Catheter ablation for Atrial Fibrillation
• Point to point RFA, linear, or single shot
device ablation
• Persistent PVI is difficult to achieve (rate of
reconnection 70%)
• Small studies  extra pulmonary foci
ablation (esp LAA) improve outcome
• Conversion success rate 85% (1-year) and
52% (5-year)
• Generally indicated in failed with AAD

Table 16 Procedure-related complications in catheter ablation and
thoracoscopic ablation of AF (1)
Complication severity Complication type Complication rate
Catheter ablation Thoracoscopic ablation
Life-threatening Periprocedural death <0.1% <0.1%
complications Oesophageal perforation/fistula <0.5% N/A
Periprocedural thromboembolic <1.0% <1.5%
event
Cardiac tamponade ≈1% <1.0%
Severe complications Pulmonary vein stenosis <1.0% N/A
Persistent phrenic nerve palsy <1.0% N/A
Vascular complications 2-4% N/A
Conversion to sternotomy N/A <1.7%
©ESC
Pneumothorax N/A <6.5%
NA = not available.
Table 16 Procedure-related complications in catheter ablation
and thoracoscopic ablation of AF (2)
Complication severity Complication type Complication rate
Catheter ablation Thoracoscopic ablation
Moderate or minor Various 1−2% 1−3%
complications
Complications of Asymptomatic cerebral 5−15% N/A
unknown significance embolism
NA = not available.
©ESC
Principles for long term AAD
Benefit > risk

A Stroke
● Rate Control

and management

Figure 18 Contribution of
AF risk factors to the
development of an
abnormal substrate
translating into poorer
outcomes with rhythm
control strategies
Several AF risk factors may contribute to the development

of LA substrates and thus affect the outcome of AF
catheter ablation, predisposing to a higher recurrence
©ESC
rate. Aggressive control of modifiable risk factors may
reduce recurrence rate
©ESC
Table 15 Goals of follow-up after cardioversion of AF
Goals
Early recognition of AF recurrence by ECG recording after cardioversion
Evaluation of the efficacy of rhythm control by symptom assessment
Monitoring of risk for proarrhythmia by regular control of PR, QRS, and QTc intervals
Evaluation of balance between symptoms and side-effects of therapy considering QoL and
symptoms
Evaluation of AF-related morbidities and AAD-related side-effects on concomitant
cardiovascular conditions and LV function
Optimization of conditions for maintenance of sinus rhythm including cardiovascular risk
management (BP control, HF treatment, increasing cardiorespiratory fitness, and other
measures.
©ESC
Beyond Drugs and Ablation
Brandes et al. clinical review : arrhythmias. 2018

Lifestyle Goals in Managing Atrial
Fibrillation
Brandes et al. clinical review : arrhythmias. 2018

Atrial Flutter
•Mostly regular rhythm → Regular
Narrow Complex Tachycardia
•Sawtooth P Waves Appearance
•Atrial rate 200-400 bpm (most
common 150 bpm with 2:1 ratio)
•Loss of Iso-electrical Baseline
Etiology
Atrial flutter is a type of SVT caused by a re-entry circuit within
the right atrium. Length of the re-entry circuit corresponds to the
size of the right atrium, resulting in an atrial rate of around 300
bpm (range 200-400).
● Ventricular rate is determined by the AV conduction ratio
(“degree of AV block”). Most common is 2:1, resulting in a
ventricular rate of ~150 bpm.
● Higher-degree AV blocks (usually due to medications or
underlying heart disease)-> lower rates of ventricular
conduction, e.g. 3:1 or 4:1 block.
● Atrial flutter with 1:1 conduction can occur due to
sympathetic stimulation or in the presence of an accessory
pathway — especially if AV-nodal blocking agents are
administered to a patient with WPW.
● Atrial flutter with 1:1 conduction is associated with severe
haemodynamic instability and progression to VFib
AFL Risk Factors
Age- and sex- Multivariable-
Variables adjusted OR P-value adjusted OR P-value
Smoking 2.83 (1.66–4.81) 0.0001 2.84 (1.54–5.23) 0.0008

Moderate-to-heavy alcohol use 2.73 (1.25–5.98) 0.01 2.20 (0.92–5.25) 0.08
Body mass index 0.94 (0.76–1.16) 0.56 0.91 (0.71–1.15) 0.43

Heart rate 1.11 (0.90–1.37) 0.35 1.13 (0.87–1.47) 0.35
PR interval 1.28 (1.05–1.55) 0.01 1.28 (1.03–1.60) 0.03
Systolic blood pressure 0.97 (0.78–1.20) 0.78 0.98 (0.76–1.27) 0.88
Hypertension treatment 1.11 (0.72–1.73) 0.63 1.21 (0.74–1.97) 0.44
Diabetes mellitus 0.95 (0.49–1.83) 0.87 0.99 (0.46–2.11) 0.98
Valvular heart disease 0.60 (0.21–1.71) 0.34 0.43 (0.12–1.54) 0.19
History of myocardial infarction 2.44 (1.36–4.38) 0.003 2.25 (1.05–4.80) 0.04
History of heart failure 5.40 (1.95–14.98) 0.001 5.22 (1.26–21.64) 0.02

Management approach
ABC pathway largely applies
Rate control is first step in symptom management
Cardioversion to sinus rhythm may be more effective, especially electrical
cardioversion or (where feasible) high-rate stimulation
Drug Therapy
Class III AADs dofetilide and ibutilide i.v. very effective in interrupting AFL,
Class Ic drugs flecainide and propafenone should not be used in the absence
of atrioventricular-blocking drugs as they may slow the atrial rate -> 1 : 1
atrioventricular conduction with RVR
NON-PHARMACOLOGIC DRUGS FOR DRUGS FOR ANTICOAGULANT
TREATMENT CONVERSION TO PREVENTION OF DRUGS
SINUS RHYTHM RECURRENCE
DC-synchronised shock (50 Less effective than Non- None has proven effect Same recommendation as
J) is the most effective acute Pharmacologic for Atrial Fibrillation
treatment Treatment
Atrial overdrive pacing Ibutilide, Dofetilide Dofetilide, Flecainide Anticoagulation therapy is

(transvenous or indicated for all patients with
transoesophageal) atrial flutter except those with
contraindication and except
patients with "lone" atrial
flutter
Radiofrequency ablation (as the Betablockers, Calcium

first line treatment or as channel blockers (?)
prevention of recurrence)
Terima Kasih

Atrial Fibrillation and Atrial Flutter Jimmy Asaf

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Atrial Fibrillation and Atrial Flutter

ESC AF guidelines 2020

individuals) (European Heart Journal 2020-doi/10.1093/eurheartj/ehaa612)

ESC AF guidelines 2020

ESC AF guidelines 2020

Iwasaki et al. Circulation. 2011

• Source of focal ectopic impuls:

Braunwald’s heart disease, 2019

Sensitivity and Specificity of AF screening tools compared to 12-lead ECG

Method Sensitivity Specificity

Pulse taking 87-97% 70-81%

Automated BP monitor 93-100% 86-92%

Single lead ECG 94-98% 76-95%

Smartphone apps 91.5-98.5 91.4-100%

Watches 97-99% 83-94%

Cardiovascular Risk Factors and ● Lifestyle Intervention

Recommendations Class Level

Recommendations Class Level

Braunwald heart disease, 2019

More effective and

Braunwald’s heart disease, 2019

ESC guidelines AF 2020

Cardiovascular Risk Factors and ● Lifestyle Intervention

ESC guidelines AF 2020

ESC guidelines AF 2020

Cardiovascular Risk Factors and ● Lifestyle Intervention

ESC guidelines AF 2020

Pedoman AF PERKI 2014

ESC guidelines AF 2020

Benefit > risk

ESC guidelines AF 2020

Cardiovascular Risk Factors and ● Lifestyle Intervention

ESC guidelines AF 2020

Several AF risk factors may contribute to the development

Brandes et al. clinical review : arrhythmias. 2018

Brandes et al. clinical review : arrhythmias. 2018

Smoking 2.83 (1.66–4.81) 0.0001 2.84 (1.54–5.23) 0.0008

Body mass index 0.94 (0.76–1.16) 0.56 0.91 (0.71–1.15) 0.43

History of heart failure 5.40 (1.95–14.98) 0.001 5.22 (1.26–21.64) 0.02

Atrial overdrive pacing Ibutilide, Dofetilide Dofetilide, Flecainide Anticoagulation therapy is

Radiofrequency ablation (as the Betablockers, Calcium

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