ATRIAL FIBRILLATION

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ATRIAL
FIBRILLATION

• An overview by Matt Hall
• Preceptor Dr Lester Mercuur

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Acute Management of AF

• A three-part approach to the acute management of
  AF should be considered
• Appropriate control of the ventricular rate.
• The need for, proper timing of, and the
  appropriate method for the
• restoration of sinus rhythm.
• The need for anticoagulation to prevent
  thrombo-embolism.

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Order of Algorithm

• Haemodynamic stability
• Assess state of hydration
• Ventricular Rate Control
• Clinical category of AF
• Risk-stratifying the cardioversion decision
• Anticoagulation considerations
• Disposition decisions

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Introduction

• Most common sustained arrhythmia
• More prevalent in men and with increasing age
• Overall prevalence of AF is 1. 70 are at least
  65 years old and 45 are over 75
• Prevalence ranges from 0.1 in adults lt55 to 9in
  those gt80
• AF uncommon in infants and children, almost
  always occurring with structural heart disease
• Accounts for gt5 cardiac admissions

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Classification

• LONE AFAF without structural heart disease
• PAROXYSMAL AF Self terminating AF in which the
  episodes of AF last lt7 days (usually lt24hrs) and
  may be recurrent
• PERSISTENT AF Not self terminating and last gt7
  days
• PERMANENT AF AF lasting gt1 year and
  cardioversion has failed or not been attempted

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Etiology Cardiac

• Hypertension (1.5x)
• Coronary heart disease (6-10)
• Rheumatic heart disease (16-70)
• CHF (10-30)
• Cardiomyopathy (10-28)
• Myocarditis
• Post cardiac sx (30-60)
• Pericarditis
• Congenital heart disease

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Etiology Non Cardiac

• Hyperthyroidism (20-25)
• Pulmonary embolism (10-14)
• Obstructive sleep apnea
• Noncardiac surgery (4.1)
• Alcohol (60 binge drinkers-holiday heart)
• Caffeine
• Hypothermia
• Medications (theophylline)

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Symptoms and Signs

• Palpitations
• Fatigue
• Presyncope/syncope
• Dyspnea/Chest Pain
• Neurologic Deficit
• Irregularly irregular HR
• Absent a wave in JVP
• Variable S1
• Murmur

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Evaluation

• History and Physical
• Define symptoms
• Clinical type
• Onset of discovery of AF
• Frequency/duration of AF episodes
• Precipitating Causes
• Modes of termination
• Response to drug therapy
• Presence of heart disease/reversible cause
  
  
  

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Evaluation cont

• ECG Verify presence of AF
• Identify LVH
• Pre-excitation
• BBB
• Prior MI
• P wave duration and morphology
• Measure intervals RR,QRS, QT

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AF with pre-excitation
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AF with pre-excitation
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AF with pre-existing BBB
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Differences

• Pre-excitation
• Varying QRS width and morphology

• Existing BBB
• Identical QRS morphology

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Evaluation cont

• LaboratoryCBC
• INR/PTT
• Electrolytes
• Creatinine
• TSH
• CXR
• Echocardiogram
• Additional TEE, Holter, Stress test, Cardiac
  Catheterization, EPS

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Acute Management of AF

• A three-part approach to the acute management of
  AF should be considered
• Appropriate control of the ventricular rate.
• The need for, proper timing of, and the
  appropriate method for the
• restoration of sinus rhythm.
• The need for anticoagulation to prevent
  thrombo-embolism.

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RATE VS RHYTHM CONTROL

• Favours rate control
• Persistent AF
• Recurrent AF
• Less Symptomatic
• gt65 years old
• Hypertension
• No Hx CHF
• Previous antiarrythmic drug failure
• Patient preference

• Favours Rhythm Control
• Paroxysmal AF
• First episode AF
• More symptomatic
• lt65 years old
• No hypertension
• Hx of CHF
• No previous failure of
  antiarrythmic drugs
• Patient preference

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Order of Algorithm

• Haemodynamic stability
• Assess state of hydration
• Ventricular Rate Control
• Clinical category of AF
• Risk-stratifying the cardioversion decision
• Anticoagulation considerations
• Disposition decisions

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Ventricular rate control

• Beta-Blockers
• Calcium Channel Blockers
• Digoxin
• (Amiodarone)

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WHICH ONE??

• Beta Blockers
• High adrenergic tone (eg post-op AF)
• Good choice if ventricular response increases
  excessively during exercise
• Exercise induced angina
• Setting of acute MI or Heart Failure
• Thyrotoxicosis
• Calcium Channel Blockers
• No structural heart disease
• COPD

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Which One??

• Digoxin
• Usually ineffective alone (NOT 1st Line)
• Synergistic with other drugs
• LV Dysfunction /- CHF
• Amiodarone
• Effective for rate and maintenance of sinus
  rhythm after
  cardioversion (but at what cost)

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Acute Management of AF

• A three-part approach to the acute management of
  AF should be considered
• Appropriate control of the ventricular rate.
• The need for, proper timing of, and the
  appropriate method for the
• restoration of sinus rhythm.
• The need for anticoagulation to prevent
  thrombo-embolism.

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The need for cardioversion- Clinical category
A wide clinical spectrum exists

• - Asymptomatic to life-threatening
• - Paroxysmal vs. chronic/permanent AF
• - Normal heart vs. Diseased heart
• Risk of stroke

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The need for cardioversion- Considerations
The frequency of the paroxysms of AF the
severity of the associated symptoms, and the
degree of underlying heart disease all need to
be considered when determining the need to
restore and maintain sinus rhythm.
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The need for cardioversion
AF Spectrum
Diseased heart with poor LV function
Normal heart
Infrequent episodes with severe symptoms
Frequent asymptomatic paroxysms
Paroxysmal
Persistent/Permanent
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The need for cardioversion

• An attempt at cardioversion is reasonable with
• lone AF (lt 65 years with structurally normal
  hearts)
• first episode/ new onset AF
• patients who are very symptomatic during AF
  despite adequate ventricular rate control
• patients with infrequent symptomatic paroxysmal
  atrial fibrillation.

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The need for cardioversion
Patients with minimal symptoms and in whom
factors have been identified which make
cardioversion and maintenance of sinus rhythm
less likely, may benefit from ventricular rate
control and anticoagulation alone.
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Need for Urgent Cardioversion

• Ischemic Chest Pain
• Acute MI
• Hypotension
• Pulmonary Edema
• Syncope

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The timing of cardioversion
Key to the timing of cardioversion is the risk of
thrombo-embolism.
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The timing of cardioversion

• Factors associated with increased thromboembolic
  risk
• AF gt 48 hours in duration or unknown duration.
• Valvular heart disease particularly mitral
  valve disease
• Significant LV dysfunction (LVEF lt 40) or
• clinical heart failure
• Previous CVA/TIA/peripheral arterial embolism
• Hyperthyroidism
• Atrial Septal Defect (even if repaired)

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The timing of cardioversion
Patients who have - any risk factors, - or
when there is doubt about the risk need measures
to ensure the absence of LA thrombus before
cardioversion is attempted. For those with a
sub-therapeutic INR, the TEE-guided strategy or
the conventional strategy of delayed
cardioversion is recommended.
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The timing of cardioversion

• Patients who are already on warfarin and who
  have had a therapeutic INR for at least the
  preceding three weeks, may undergo cardioversion
  in the emergency department if indicated.

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The timing of cardioversion
Patients who have no risk factors, and who have
AF lt 48 hours (preferably lt24 hours) in duration,
may undergo immediate cardioversion without the
need exclude LA thrombus
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Electrical Cardioversion

• Have all supplies needed (Monitors ,IV,
  Intubation equipment, extra staff..etc)
• Premedicate
• Synchronized cardioversion (100,200,300,360J)

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Drugs For Conversion of AFCCS Consensus

• Ibutilide (Level of evidence A)
• Flecainide (A)
• Procainamide (B)
• Propafenone (A)
• Amiodarone (B)

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So what is the real danger?
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Acute Management of AF

• A three-part approach to the acute management of
  AF should be considered
• Appropriate control of the ventricular rate.
• The need for, proper timing of, and the
  appropriate method for the
• restoration of sinus rhythm.
• The need for anticoagulation to prevent
  thrombo-embolism.

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Stroke and AF
Disabling stroke is the most devastating
complication of AF
Age, hypertension and previous stroke/TIA are the
strongest predictors of ischemic stroke in
patients with intermittent and sustained AF.
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Stroke and AF
The risk of stroke is the same in intermittent AF
and permanent AF. The risk of thrombo-embolism
does not differ between electrical or
pharmacological cardioversion Spontaneous
cardioversion is also associated with
thrombo-embolic risks.
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Risk of stroke
AF Spectrum
Diseased heart with poor LV function
Normal heart
Advanced age
Young
No additional stroke risk factors
Numerous other additional stroke risk factors
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Recommendations for long-term anti-thrombotic
therapy in AF
ANY High risk criterion - Warfarin therapy TWO or
more Moderate criteria - Warfarin therapy ONE
Moderate risk criterion - Warfarin therapy or
Aspirin LOW risk criteria - Aspirin therapy
325mg
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Bottom line

• Treatment should be carefully tailored to
  individual circumstance.
• Not all patients need cardioversion
• Defined role for attempting cardioversion
• When there is doubt about thrombo-embolic risk,
  cardioversion should be deferred
• Anticoagulation recommendations reduce the burden
  of ischemic stroke

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AF Order Set and Discharge Summary

• Order Set
• Physician orders Labs
• Nursing interventions
• Drugs and dosages
• Discharge Summary
• Referral tool to Cardiology/ Internal Med/ Family
  Physician

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Cases

• 35 yo male with AF with rapid Ventricular
  response following an alcoholic binge. C/O
  palpitations x 3 hrs. Never before.
• 88 yo female with significant CHF hx/HTN
  Presents with increased SOB. Hx AF.has been on
  many drugs and shocked few times in past.
  Coumadin in past. HR hasnt been a problem for
  sometime. Denies CP/Palp. Current meds include
  Lasix, Carvediol, Ecasa, Digoxin, Altace. ECG
  shows AF rate 135, no ischemic changes. CXR
  looks wet.

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Cases

• 75 yo female with CAD Hx, DM, HTN presenting with
  cough/SOB. Denies CP. CXR shows RLL pneumonia
  and ECG shows AF rate 125. Meds ECASA 81,
  Metoprolol 50 bid, Metformin 500 tid

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Cases

• 69 yo 100 kg male, sweaty, diaphoretic c/o chest
  pain. AF present at rate of 150. Cardioversion
  not successful. Patient is deterioratingwhat
  now??

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Cases

• 70 yo male c/o SOB, CP, diaphoresis. No CAD hx.
  Has had HTN x many years and hx AF with previous
  stroke. Meds include Atenolol, water pill, and
  coumadin. ECG shows AF with rate of 120 and ST
  elevation inf leads. INR 1.4
• 70 yo male presents with typical Anginal pain
  with CAD hx. Has had HTN, MI and AF. Meds
  include B-blocker, Ace, Ecasa 81, Coumadin,
  Statin. Ecg shows AF with rate of 145 but no
  ischemic changes. INR 1.3

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Note

• In absence of a reversible cause, AF is usually
  recurrent(75 with no antiarrythmic drugs)
• AF begets AF (electrical remodeling) ? ACE
• A persistent rapid rate can result in tachycardia
  induced cardiomyopathy
• Rate control should be assessed at rest and with
  exercise
• In patients with rapid ventricular rate with
  pre-excitation over an accessory bypass tract
  (WPWS) administer IV procainamide or ibutilide or
  perform DC cardioversion if unstable (avoid B
  blockers ,Ca Blockers, adenosine, digoxin)

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THE END