Atrial Fibrillation

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Atrial Fibrillation

• Rate or rhythm control?
• Who should be anticoagulated?
• Other treatment strategies

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Classification
Aetiology
LONE AF
VS
ALCOHOL RHEUMATIC HYPERTENSION HYPER
THYROIDISM ISCHAEMIC ETC
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Classification
Timing
Aetiology
FIRST EPISODE
LONE AF
OR
VS
ALCOHOL RHEUMATIC HYPERTENSION HYPER
THYROIDISM ISCHAEMIC ETC
RECURRENT
PERSISTENT
PAROXYSMAL
PERMANENT
Circulation 20011042118 2150
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Prevalence of AF
JAMA. 20012852370-2375
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Mechanism of AF
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Mechanism of AF
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Mechanism of AF
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Burden of AF
Palpitations
AF 5 gt 65
Syncope/Presyncope
Fatigue
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Burden of AF
Palpitations
AF 5 gt 65
Syncope/Presyncope
Fatigue
DyspnoeaOedema
Heart Failure
Stroke
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Prognosis of AF
Circulation 199898946-952
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Principles of management

1. RESTORATION MAINTENACE OF SINUS
   RHYTHM Rhythm control
2. CONTROL OF VENTRICULAR RATE Rate control
3. REDUCE THROMBOEMBOLIC RISK

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Restoration of SR
RESTORATION OF SINUS RHYTHM
NB 60 REVERT SPONTANEOUSLY IN lt24 HOURS
ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK

• PHARMACOLOGICAL
• 1) FLECAINIDE
• 2) PROPAFENONE
• 3) AMIODARONE
• 4) DOFETILIDE

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Restoration of SR
ANTICOAGULATION?
RESTORATION OF SINUS RHYTHM
HOW LONG IN AF?
NB 60 REVERT SPONTANEOUSLY IN lt24 HOURS
ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK

• PHARMACOLOGICAL
• 1) FLECAINIDE
• 2) PROPAFENONE
• 3) AMIODARONE
• 4) DOFETILIDE

lt48 HOURS NO HEPARIN 3 WEEKS WARFARIN POST
SHOCK
gt48 HOURS 3 WEEKS WARFARIN PRE POST
SHOCK or TOE GUIDED SHOCK 3 WEEKS
WARFARIN POST SHOCK
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Maintenance of SR (prevention of AF recurrences)
1) DRUG TREATMENT
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Maintenance of SR (prevention of AF recurrences)

• 2) OTHER TREATMENTS
• Pacing
• Atrial Defibrillators
• Cardiac Surgery
• Catheter radiofrequency ablation

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Rate control
VENTRICULAR RATE CONTROL
PHARMACOLOGICAL 1) DIGOXIN 2) ? BLOCKER 3) CA
CHANNEL BLOCKER 4) AMIODARONE

• ABLATION
• RADIOFREQUENCY
• ABLATION OF
• ATRIOVENTRICULAR NODE
• PACEMAKER

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Rate vs rhythm control
Rate (Remain in AF) Rhythm (Restore
SR) advantages Good symptom
control Good symptom control Simple low risk
treatment Normal physiology/cardiac function
Better prognosis ?? disadvantages Abnorm
al cardiac function Complex higher risk
treatment Stroke risk ?? Antiarrhythmic drugs
- proarrhythmic Worse prognosis??
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Rate vs rhythm control - PIAF
PIAF study Lancet 20003561789-94
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Rate vs rhythm control AFFIRM
n 4000 ? age 70

• Rate
• Digoxin
• ? Blocker
• Ca channel blocker

• Rhythm
• Amiodarone
• Propafenone
• Sotalol
• /- DC Cardioversion

AFFIRM study - NASPE 2002
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Risk of Stroke?

• 1 in 6 strokes have AF
• 6 x stroke rate if have AF
• TYPE OF AF IS NOT A RISK DETERMINANT

Optimal INR?
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Who should be anticoagulated?
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