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Atrial Fibrillation

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Atrial fibrillation/flutter is a disorder of heart rhythm (arrhythmia) usually ... Electrocardiogram: Presence of AF. Left ventricular hypertrophy. Preexcitation ... – PowerPoint PPT presentation

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Title: Atrial Fibrillation


1
Atrial Fibrillation
  • Andreas Stein
  • Robert Smith, M.D.
  • August 11, 2003

2
Definition
Atrial fibrillation/flutter is a disorder of
heart rhythm (arrhythmia) usually with rapid
heart rate, in which the upper heart chambers
(atria) are stimulated to contract in a very
disorganized and abnormal manner.
3
Prevalence
  • Overall prevalence 1
  • Increases with age
  • Higher in men than in women

4
Classification
  • Paroxysmal AF less than 7 days
  • Persistent AF longer than 7 days
  • Permanent AF longer than 1 year
  • Lone AF no structural heart disease

5
Etiology
  • AF with Heart disease complicated by the
    following is most common (80)
  • Atrial enlargement
  • Elevation of atrial pressure
  • Infiltration or inflammation of atria
  • Lone AF (20)
  • Electrophysiologic properties

6
Etiology (cont)
  • Common diseases underlying AF
  • Hypertension
  • Coronary Heart disease / MI
  • Rheumatic heart disease
  • Dilated cardiomyopathy
  • Hypertrophic cardiomyopathy
  • Congenital heart disease
  • Hyperthyroidism
  • Inflammation

7
Evaluation of AF
  • History and Physical Examination
  • Define symptoms associated with AF
  • Clinical type or pattern (Classification)
  • Onset or date of discovery
  • Frequency and Duration
  • Precipitating causes and modes of termination
  • Response to drug therapy
  • Presence of heart disease or potentially
    reversible causes

8
Evaluation of AF (cont)
  • Electrocardiogram
  • Presence of AF
  • Left ventricular hypertrophy
  • Preexcitation
  • Bundle branch block
  • Prior MI
  • Measure important intervals such as RR, QRS and
    QT

9
Evaluation of AF (cont)
  • Echocardiogram
  • Transthoracic Echocardiogram
  • size and function of atria and ventricles
  • low sensitivity for thrombi
  • Transesophageal Echocardiogram
  • High sensitivity for atrial thrombi
  • Need of anticoagulation prior to cardioversion
  • Assessment for Hyperthyroidism
  • TSH measurement

10
General Treatment Issues
  • Rhythm control
  • reversion to normal sinus rhythm
  • Rate control
  • administration of medications to control the
    ventricular rate in chronic AF
  • Choosing between rhythm and rate control
  • Prevention of systemic embolization

11
Rhythm Control
  • Synchronized External DC Cardioversion
  • hemodynamically stable and unstable patients
  • 80 overall success rate
  • Pharmacologic Cardioversion
  • hemodynamically stable patients
  • Class IA IC III anti arrhythmic drugs
  • 60 overall success rate

Rule out atrial thrombi by TEE or
anticoagulation for 3 4 week
12
Drugs for AF lt7 Days
13
Drugs for AF gt7 Days
14
Maintenance of NSR
  • 20 maintain in NSR without chronic
    anti-arrhythmic therapy
  • Class IA, IC, and III drugs
  • Flecainide ? minimal heart disease
  • Amiodarone ? reduced EF
  • Sotalol ? coronary heart disease
  • Alternative methods
  • ablative procedures
  • pacing
  • insertion of an implantable atrial defibrillator

15
Maintenance of NSR
16
Rate control in chronic AF
  • Slowing AV nodal conduction
  • beta blocker
  • calcium channel blocker
  • digoxin

17
Rhythm Control vs. Rate Control
  • Embolic events occur with equal frequency in rate
    control and rhythm control strategies
  • Almost significant trend toward a lower incidence
    of the primary end point with rate control

18
Prevention of Systemic Embolization
  • Anticoagulation during restoration of NSR
  • AF gt 48 hours 3 to 4 weeks of warfarin prior to
    and after cardioversion
  • recommended target INR is 2.5
  • Anticoagulation in chronic AF
  • Aspirin low risk patients (lt65y no risk
    factors)
  • Warfarin other than low risk patients
    70 reduction of stroke

19
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