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Description : Comprehensive approach on atrial fibrillation, including pharmacological and surgical treatment

Tags : A Fib

Published on : Aug 11, 2020 | Views : 8210 | Downloads : 103

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A Comprehensive Approach ATRIAL FIBRILLATION
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Atrial fibrillation (AF) is the most common cardiac arrhythmia Irregularly irregular narrow complex tachycardia due to irregular atrial activation at a rate of 350-600bpm with irregular conduction through the AV node. Spontaneous discharge by ectopic pacemaker cells in large pulmonary veins at point where they join LA General Characteristics
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Diagnostic: Absence of P waves Typically irregularly irregular R-R intervals Irregular fibrillatory waves (F waves) Heart Rate (typically 110-140 beats/min, rarely 160-170 beats/min) Electrocardiographic Features
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Other Features: Ashman phenomenon Left Ventricular Hypertrophy Acute or prior myocardial infarction Preexcitation
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Incidence increases with age More common in whites than blacks More common in men than women 0.1% below 55 years 3.8% 60 years or older 10% 80 years or older Incidence
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Atrial structural abnormalities Hemodynamic Stress Atrial and Ventricular Ischemia Atrial Inflammation Electrophysiological mechanisms Other pathophysiological mechanisms Pathophysiology
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Paroxysmal AF : spontaneous termination < 7 days Persistent AF: episodes that last more than 7 days and may require either pharmacological or electrical intervention to terminate Long Standing Persistent AF: Persistent AF for more than 1 year Permanent AF: When both patient and clinician have decided to abort any further restoration strategies Classification
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Patient condition ranges from asymptomatic to cardiogenic shock or cerebrovascular accident Evaluate vital signs for hemodynamic dysfunction Irregularly irregular pulse, most commonly tachycardia. (Patients who are hypothermic or have cardiac drug toxicity may present bradycardia atrial fibrillation) Physical Examination may demonstrate signs of precipitating factor or sequelae of Afib. Clinical Features
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Electrocardiography Laboratory Studies: CBC UCE CK/ Troponin BNP D-dimer TFT Imaging Studies CXR CT Scanning (CTA to rule out PE) Workup
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Transthoracic Echocardiography Evaluate for valvular heart disease Evaluate atrial and ventricular chamber and wall dimensions Estimate ventricular function and evaluate ventricular thrombi Estimate pulmonary systolic pressure Evaluate for pericardial disease Transesophageal echocardiography Evaluate for atrial thrombus (particularly in LA appendage) To guide cardioversion (if thrombus is seen, cardioversion should be delayed) Echocardiography
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Establish a diagnosis in cases of paroxysmal AF not evident on presentation Evaluate rate control HOLTER MONITOR
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Systemic Thromboembolism CVA or TIA Pulmonary Embolism Splenic Infarct Tachycardia Induced Cardiomyopathy Cardiogenic Shock Complications
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Stroke With A Fib
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PRINCIPLES: Rhythm Control AND/OR Rate Control Thromboembolic Risk Prevention MANAGEMENT
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For Hemodynamically unstable patients: Includes: hypotension, decompensated CHF, uncontrolled angina/ischemia Sedate if possible and perform an immediate cardioversion If refractory to cardioversion, use IV amiodarone, ibutilide or procainamide For Hemodynamically stable patients: Initiate anticoagulation and rate control Consider cardioversion after adequate anticoagulation (4 weeks) or no clot seen on TEE and therapeutic anticoagulation initiated. Rule out secondary causes Management of New-Onset AF
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Principles: CV may be achieved by pharmaceuticals or electric shock Direct Current CV is more effective than pharmacological CV The more recent the onset of AF, the more effective is pharmacological CV Main disadvantage of electrical CV is it requires sedation or anesthesia Primary disadvantage of pharmacological CV is the risk of ventricular proarrythmia The risk of thromboembolism or stroke does not differ between pharmacological and electrical CV Significant sinus bradycardia after CV can occur in patients on high dose AV nodal blocking drugs Cardioversion
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Focus: Reduce AF Recurrence Reduce AF-Related Symptoms Control of Ventricular Rate Reducing Stroke Risk Long Term Management
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Rate Control Indications: Age > 65, less symptomatic, hypertension Recurrent AF Previous antiarrythmic drug failure Unlikely to maintain sinus rhythm (enlarged LA) Rhythm Control Indications: First Episode AF Reversible Cause Symptomatic despite rate control Patient unable to take anticoagulant CHF precipitated or worsened by AF Young Patient Rate vs. Rhythm Control
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Beta Blockers and Calcium Channel Blockers are first line agents Digoxin can be used in acute setting but does little to control ventricular rate in active patients. (Rarely used as monotherapy) Amiodarone is used when patients are intolerant of or unresponsive to other agents (caution in patients who are not receiving anticoagulation as can promote cardioversion) Target Rate <110 bpm at rest Caution in Pre Excitation syndrome - blocking AV node Impulses down accessory pathway Ventricular fibrillation In the presence of tachycardia mediated cardiomyopathy or inadequate ventricular rate control: AV Nodal ablation and Permanent pacemaker implantation may be considered. Rate Control
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Pace Maker
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Amiodarone Drug of choice in ptes with coronary artery disease or HF Dronedarone structurally similar to amiodarone but less effective and associated with increased mortality. Not recommended in Permanent AF or Class III or IV HF Sotalol Efficacious in maintaining sinus rhythm Associated with risk of QT interval prolongation and torsade de pointes AF Ablation (catheter, surgical, hybrid) Ptes with symptomatic paroxysmal AF intolerant/ refractory to drugs Ptes with symptomatic persistent AF intolerant / refractory to drugs Rhythm Control
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AF ABLATION
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The CHA2DS2-VASc Score (formerly CHADS2) uses a point system to determine yearly thromboembolic risk Thromboembolic Risk Prevention
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For patients with AF and an elevated CHA2DS2-VASc score of 2 or greater in men or 3 in women, oral anticoagulants are recommended. Adding female sex to the CHA2DS2-VASc score matters for age >65 or >= 2 non sex related stroke risk factors Non- Vitamin K oral anticoagulants recommended over Warfarin (except those with moderate to severe mitral stenosis or a mechanical heart valve) Warfarin is recommended in patients with AF who have mechanical heart valves. Aspirin is no longer recommended for patients with low CHA2DS2VASc scores. Use oral anticoagulant. 2019 ACC/AHA/HRS Updated Guidelines
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For each anticoagulant, the benefit in terms of stroke reduction must be weighed against the risk of clinically significant bleeding Bleeding Risk Assessment is determined using the HAS-BLED Score: High Risk > 4 Moderate Risk 2-3 Low Risk 0-1 Risk Management Decisions
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Anticoagulation Effective anticoagulation in patients with AF reduces the risk of stroke 3 fold after 4-6 weeks Anticoagulation Strategies: Warfarin bridged with Intravenous Heparin or LMWH NOACs (Dabigatran, Rivaroxaban, Apixaban, Endoxaban) Left Atrial Appendage Ligation Suitable as long term stroke prophylaxis in patients with Non valvular AF
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Warfarin Therapeutic INR in AF usually between 2 -3 Interferes with hepatic synthesis of Vitamin K dependent clotting factors (II, VII, IX and X) Patients who are at significant risk for stroke (prior stroke, RHD, Artificial valves) INR goal is 2.5 to 3.5 Patients who have a high risk for fall, INR goal 1.8 to 2 Has no effect on established thrombus Frequent adverse effects: haemorrhage, skin necrosis within first few days, cholesterol embolization to skin or visceral organs in first few weeks. Medications
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Dabigatran Direct thrombin inhibitor 110 mg BD (same efficacy as Warfarin, less bleeding risk) 150 mg BD (FDA approved, significantly more effective than Warfarin, same bleeding risk) 75mg BD (EGFr 15-29ml/min) Increased risk of ACS Contraindicated in prosthetic heart valves, hemodynamically significant valve disease, severe renal failure and advanced liver disease.
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Rivaroxaban 20mg OD (normal renal function) 15mg OD (EGFr 30-49ml/min) Loading dose not required Major Bleeding risk was similar to warfarin but lower risk of intracranial haemorrhage and fatal bleeding. Non inferior in thromboembolic prevention Apixaban Superior in systemic embolism prevention, less bleeding and lower mortality compared to warfarin. Dosis: 5mg PO BD Edoxaban Non inferior to warfarin in thromboembolic prevention and superior for all types of bleeding except gastrointestinal (low dose 30 OD) High dose (60mg daily) lower bleeding risk than warfarin FDA recommends avoiding in ptes with EGFr of 95 mL/min or greater Direct Factor Xa Inhibitors
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Left Atrial Ligation
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Management of Toxicity Warfarin Prothrombin Complex Concentrates (complete reversal in 15-20 minutes) Fresh Frozen Plasma (6 – 24hrs) NOACs: (short acting, reversal rarely indicated) Dabigatran: Idarucizumab (two doses 15 mins apart reverses in 10-30mins) Factor Xa inhibitors: Andexanet alfa (Under Clinical Trials)
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Postoperative AF – recommended perioperative BB Hyperthyroidism – BB, if contraindicated: Non DHP CCBs COPD – Non DHP CCBs drug of choice Heart Failure BB/ Non DHP CCBs are used in persistent or permanent AF Digoxin/ Amiodarone useful in acute setting WPW and Pre-excitation Syndromes IV procainamide or ibutilide drugs of choice IV amiodarone, adenosine, digoxin, non DHP CCBs are potentially harmful Special Considerations
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THANK YOU