2. Management of Atrial Fibrillation
Dr.Ajmal Khan
TMO Cardiology HMC

3. The Consequences of AF Thromboembolism Mortality Hospitalizations
Stroke: 4.5 increased risk
Microemboli: reduced cognitive function
Prothrombotic state
Mortality
2 increased risk independent of comorbid CV disease
Sudden death in HF and HCM
Hospitalizations
Most common arrhythmia requiring hospitalization
2-3 increased risk for hospitalization
Impaired Hemodynamics
Loss of atrial kick
Irregular ventricular contractions HF
Tachycardia-induced cardiomyopathy
Reduced QoL
Palpitations, dyspnea, fatigue, reduced exercise tolerance
AF is an enormous contributor
to the growing cost of medical care

4. Definition
AF is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of mechanical function.
ECG shows, rapid oscillations, or fibrillatory waves that vary in amplitude, shape, and timing, replace consistent P waves, and there is an irregular ventricular response.

7. Classification Recurrent AF :(1) paroxysmal AF (2) persistent AF
(3) permanent AF

8. Classification of Atrial Fibrillation ACC/AHA/ESC Guidelines
First Detected
Paroxysmal (Self-terminating)
Persistent (Not self-terminating)
Permanent
Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation.) J Am Coll Cardiol. 2001;38:

9. Epidemiology of Atrial Fibrillation
Most common sustained cardiac arrhythmia.
0.4% to 1% in the general population.
8% in those older than 80 y.
Currently affects > 2.3 million Americans, or 1% of population.
Preferentially affects men and the elderly .
Prevalence expected to increase by ≥ 2.5-fold by
Lifetime risk of developing AF: 1 in 4 for men and women ≥ 40 years of age .
Page 9

10. Prevalence of Diagnosed AF12
Women
11.1
Men
10.3 10
9.1 8
7.3
7.2
Prevalence (%) 6
5.0
5.0 4
3.4
3.0 2
1.7
1.7
1.0
0.9
0.2
0.4
0.1
< 55
55–59
60–64
65–69
70–74
75–79
80–84
≥ 85
Age (years)
1.89 million adults in study population; N = 17,974 with AF
Go AS, et al. JAMA. 2001;285:

11. Projected Number of Patients with AF by 2050
MarketScan and Thomson Reuters Medicare Databases, 2009
Olmsted County Data, 2006
(assuming a continued increase in AF incidence)
15.9
15.2 16
Olmsted County Data, 2006
(assuming no further increase in AF incidence)
14.3
13.1 14
ATRIA Study Data, 2000
11.7 12
10.2
12.1
11.7
8.9
11.1
10.3
7.7
Patients with AF (millions)
9.4 8
6.7
8.4
7.56
5.9
7.5
5.1 6
6.8
6.1
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:
Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, Seward JB, Tsang TS. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006;114:
5.6
5.42
5.61 4
5.1
5.16
4.78
3.03
4.34
3.80
3.33 2
2.66
2.94
2.44
2.08
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
Year
ATRIA = Anticoagulation and Risk Factors in Atrial Fibrillation.
Naccarelli GV, et al. Am J Cardiol. 2009;104(11):

12. Etiologies and factors predisposing patients to AF
Electrophysiological abnormalities
Enhanced automaticity (focal AF) 
Conduction abnormality (reentry) 
Atrial pressure elevation
Mitral or tricuspid valve disease 
Myocardial disease (primary or secondary, leading to systolic or diastolic dysfunction) 
Semilunar valvular abnormalities (causing ventricular hypertrophy) 
Systemic or pulmonary hypertension (pulmonary embolism) 
Intracardiac tumors or thrombi 
Atrial ischemia
Coronary artery disease 

13. Etiologies and factors predisposing patients to AF
Inflammatory or infiltrative atrial disease
Pericarditis 
Amyloidosis 
Myocarditis 
Age-induced atrial fibrotic changes 
Drugs
Alcohol 
Caffeine 
Endocrine disorders
Hyperthyroidism 
Pheochromocytoma 

14. Etiologies and factors predisposing patients to AF
Changes in autonomic tone
Increased parasympathetic activity 
Increased sympathetic activity 
Primary or metastatic disease in or adjacent to the atrial wall
Postoperative
Cardiac, pulmonary, or esophageal 
Congenital heart disease
Neurogenic
Subarachnoid hemorrhage 
Nonhemorrhagic, major stroke 
Idiopathic (lone AF)
Familial AF

15. Diagnosis

16. CLINICAL FINDINGS History
Mild symptoms : palpitations ,sweating ,fatigue.
Severe symptoms :hypotension ,myocardial ischemia ,myocardial dysfunctions ,stroke ,mesenteric ischemia ,lower limb ischemia
Presentations of precipitating factors
Asymptomatic

17. Examination Irregularly irregular pulse Pulse deficit
Also look for Hypertension ,Thyrotoxicosis ,CCF ,MS, Pulmonary diseases ,Other causative factors.

18. Clinical evaluation in patients with AF
Electrocardiogram, to identify
Rhythm (verify AF) 
LV hypertrophy 
P-wave duration and morphology or fibrillatory waves 
Preexcitation 
Bundle-branch block 
Prior MI 
Other atrial arrhythmias 
To measure and follow the R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy 

19. Clinical evaluation in patients with AF
Transthoracic echocardiogram, to identify
Valvular heart disease 
LA and RA size 
LV size and function 
Peak RV pressure (pulmonary hypertension) 
LV hypertrophy 
LA thrombus (low sensitivity) 
Pericardial disease 
Blood tests of thyroid, renal, and hepatic function
For a first episode of AF, when the ventricular rate is difficult to control 

20. Clinical evaluation in patients with AF
Additional testing
One or several tests may be necessary. 
Exercise testing
If the adequacy of rate control is in question (permanent AF) 
To reproduce exercise-induced AF 
To exclude ischemia before treatment of selected patients with a type IC antiarrhythmic drug 
Holter monitoring or event recording
If diagnosis of the type of arrhythmia is in question 
As a means of evaluating rate control 
Transesophageal echocardiography
To identify LA thrombus (in the LA appendage) 

21. Management

22. Goals of AF Management
Reduction in the risk of CV events and hospitalizations and costs
Prevention of thrombo-embolism
Reduction of AF burden*
 QoL
 Symptoms
Reduction in mortality

23. AFib Management Treatment Options
4/14/2017 9:24 PM
AFib Management Treatment Options
VENTRICULAR
RATE CONTROL
Pharmacologic
Nonpharmacologic
ACHIEVEMENT AND MAINTENANCE OF SINUS RHYTHM
Pharmacologic
Nonpharmacologic
AFib Management Treatment Options
Major treatment strategies for atrial fibrillation are listed here and include
Ventricular rate control, mediated by drugs, devices or ablation
Achievement and maintenance of sinus rhythm, mediated by cardioversion and/or antiarrhythmic drugs, and/or ablation
Antithrombotic therapy to reduce the risk of thromboembolic complications, in combination with rate control, and as needed, with rhythm control
The clinical history and cardiovascular comorbidities of the patient presenting with atrial fibrillation will dictate the most suitable treatment option
____________________
Miller JM, Zipes DP. Therapy for cardiac arrhythmias. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia, Pa: Elsevier Saunders; 2005;I:
Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences. J Am Coll Cardiol. 2001;38:1266i-1266lxx.
ANTITHROMBOTIC THERAPY

24. Guideline-Based AF Treatment Options
Rate control
Maintenance of SR
Stroke prevention
Pharmacologic
CCBs
-blockers
Digitalis
Amiodarone
Dronedarone
Nonpharmacologic
Ablate and pace
Pharmacologic
Nonpharmacologic
Pharmacologic
Warfarin
Aspirin +/- clopidogrel
Dabigatran
Factor Xa inhibitors
Nonpharmacologic
Removal/isolation LA appendage
Class IA Class IC Class III
-blockers
Catheter ablation
Pacing
Surgery
Implantable devices
CCBs
ACE-Is, ARBs
Statins
Fish oil
Prevent remodeling 24

25. Rate and Rhythm Control Definitions
Rate control
Rest and exertion control of ventricular response
No commitment to maintaining SR
Rhythm control
Attempts restoration and maintenance of SR
Rate control required as needed
Can switch from rhythm control to rate control
Difficult to switch from rate to rhythm control as duration of AF becomes longer
ANTICOAGULATION NEEDED for either strategy
Fuster V, et al. J Am Coll Cardiol. 2006;48: 25

26. Major Trials Comparing Rhythm Strategy and Rate Strategy
Major trials include
AFFIRM
RACE
PIAF, STAF, HOT CAFE
AF-CHF
Page 26 26

27. Trials comparing rate control and rhythm control strategies in patients with AF
Reference
Patients (n)
AF duration
Follow-up (y)
Age (mean y ±SD)
Clinical events (n)
Stroke/embolism
Death
Rate
Rhythm
AFFIRM (2002)
128
4060
b/NR
3.5
70±9
88/2027
93/2033
310/2027
356/2033
RACE (2002)
124
522
1 to 399 d
2.3
68±9
7/256
16/266
18/256
18/266
PIAF (2000)
130
252
7 to 360 d 1
61±10
0/125
2/127
2/125

28. AFFIRM: All-Cause Mortality30
Rate
Rhythm 25 20
p=0.078 unadjusted 15
Mortality, %
p=0.068 adjusted 10 5 1 2 3 4 5
Time (years)
Rhythm N:
2033
1932
1807
1316
780
255
Rate N:
2027
1925
1825
1328
774
236
The AFFIRM Investigators. N Engl J Med. 2002;347:

29. Canadian Cardiovascular Society Recommendations 2011
Favors Rate Control
Favors Rhythm Control
Persistent AF
Paroxysmal AF
Newly Detected AF
Less Symptomatic
More Symptomatic
>65 years of age
< 65 years of age
Hypertension
No Hypertension
No History of Congestive Heart Failure
Congestive Heart Failure clearly exacerbated by AF
Previous Antiarrhythmic Drug Failure
No Previous Antiarrhythmic Drug Failure

30. Cardioversion of AFib Pharmacological Electrical Early onset AFib
Long-standing AFib
Electrical

31. Pharmacological Cardioversion

32. Our Goal

33. Pharmacological Cardioversion
More effective in recent-onset AFib
Class IA-IC-III drugs administered IV
Class IC favoured in non-cardiopathic patients
Class III favoured in cardiopathic patients or those with delays in conduction
Oral loading can be performed with class IC drugs
Flecainide ( mg)
Propafenone ( mg)

34. Treatment Out-of-Hospital with Class IC Drugs
Symptomatic, rare episodes of AFib
Recent onset AFib
No structural heart disease
Prior hospital experience
Good physician-patient relationship
Resting conditions for at least 4 hours

35. Pill-in-the-Pocket
In a selected (no or mild HD), risk-stratified patient population with recurrent AFib not currently taking AADs
79% developed ≥ 1 episodes of recurrent AFib during 15 ± 5m follow-up
Acute oral flecainide or propafenone successfully terminated 94% of episodes within 113 ± 84 min, with side effects in 7% of patients
Alboni P, et al. N Engl J Med (2004) 351: 2384

36. Amiodarone for Cardioversion of Recent-Onset AFib: Meta-analysis
Bolus only
Bolus+infusion
100 95
Amiodarone IV (3-7 mg/kg ± infusion g/day)
Amiodarone oral (25-30 mg/kg)
Time to conversion > 6-8 h
Amiodarone > 1.5 g/day IV > placebo
Amiodarone mg/kg oral > placebo
Amiodarone not > other AADs
Safe in patients with structural cardiopathies and low LVEF 80 69 60 55
Conversion (%) 40 34 20
2-4 h
8 h

37. Electrical Cardioversion

38. Indications
Failure of pharmacological measures for patients with AF with ongoing myocardial ischemia, symptomatic hypotension, angina, or HF.
Immediate direct-current cardioversion is recommended for patients with AF involving preexcitation when very rapid tachycardia or hemodynamic instability occurs.
AF of <48hr ---cardioversion without prior anticoagulation.
For high risk patients---IV UFH or LMWH before cardioversion.
AF of > 48 hr or uncertain duration follow the protocol of anticoagulation.

40. 2011 ACC/AHA/HRS Guidelines: Antiarrhythmic Approaches to Maintain SR in Patients with Recurrent PAF or Persistent AF*
Maintenance of SR
No (or minimal) heart disease
HTN
CAD HF
Dronedarone
Flecainide Propafenone Sotalol
Substantial LVH
Dofetilide
Dronedrone Sotalol
Amiodarone Dofetilide No
Yes
Amiodarone Dofetilide
Catheter ablation
Dronedarone
Flecainide Propafenone Sotalol
Amiodarone
Amiodarone
Catheter ablation
Catheter ablation
Dronedarone is added in parentheses here as a possible position in this table where it may become recommended in future guidelines statements.
A Safety-Driven Approach
Amiodarone Dofetilide
Catheter ablation
Catheter ablation

41. Efficacy of AADs in AF Trials
100
Amiodarone
Dronedarone 80
Sotalol
Class IC 60
Placebo
Patients in SR at 1 Year (%) 40 20
CTAF
SAFE-T
AFFIRM
DAFNE*
EURIDIS*
ADONIS
EURIDIS/
ADONIS Pooled
DIONYSOS†

42. Treatment Options for AFib Drugs to Control Ventricular Rate

43. Permanent AFib and Ventricular Rate Control
Indications for control of ventricular rate:
Failure of antiarrhythmic therapy for preventing recurrence
Alternative treatment to maintain sinus rhythm

44. Canadian Cardiovascular Society Recommendations 2011
Favors Rate Control
Favors Rhythm Control
Persistent AF
Paroxysmal AF
Newly Detected AF
Less Symptomatic
More Symptomatic
>65 years of age
< 65 years of age
Hypertension
No Hypertension
No History of Congestive Heart Failure
Congestive Heart Failure clearly exacerbated by AF
Previous Antiarrhythmic Drug Failure
No Previous Antiarrhythmic Drug Failure

46. Anticoagulation and Antiplatelet Therapy

47. AF and Stroke AF increases stroke risk 4- to 5-fold
Stroke is the most common and devastating complication of AF
Incidence of all-cause stroke in patients with AF is 5%
AF is an independent risk factor for stroke.
Risk for stroke increases with age
Stroke risk persists even in asymptomatic AF
Stroke risk persists in patients with a “high-risk” profile despite a strategy of rhythm control (AFFIRM study, RACE study)
Annual Stroke Rate (%) 10 8 6 4 2
Permanent AF
Intermittent AF
AFib is an independent risk factor for stroke; in fact, it increases the risk of stroke approximately 5-fold.1,2 It is estimated that 15% of all strokes in the United States are attributable to AFib, and the proportion increases markedly with age.1 Additionally, ischemic stroke associated with AFib is often more severe than stroke due to other causes.3 A retrospective study determined that those with AFib were more likely than those without AFib to be bedridden following a stroke (41.2% vs 23.7%, P<.0005).3 Finally, asymptomatic, or “silent,” AFib is common and may also increase the risk of stroke.4
Moderate Risk
High Risk
Low
Risk
1. Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with AF: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With AF) developed in collaboration with the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol. 2001;38:
2. Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of AF on the risk of death: the Framingham Heart Study. Circulation. 1998;98:
3. Dulli DA, Stanko H, Levine RL. AF is associated with severe acute ischemic stroke. Neuroepidemiology. 2003;22:
4. Page RL, Tilsch TW, Connolly SJ, et al. Asymptomatic or “silent” AF: frequency in untreated patients and patients receiving azimilide. Circulation. 2003;107:
©2008 sanofi-aventis U.S. LLC
Page 47

48. Approach to thromboprophylaxis in patients with AF

49. Stroke Risk Stratification in AF
CHADS2 Risk criteria score
Risk Factor
Score
Cardiac failure 1
HTN
Age ≥75 y
Diabetes
Stroke 2
Lip GY, Halperin JL. Am J Med. 2010;123(6): 49

50. CHAD2 score and stroke rate

51. Less validated or weaker risk factors Moderate-risk factors
High-risk factors
Female gender
Age greater than or equal to 75 y
Previous stroke, TIA or embolism
Age 65 to 74 y
Hypertension
Mitral stenosis
Coronary artery disease
Heart failure
Prosthetic heart valvea
Thyrotoxicosis
LV ejection fraction 35% or less
Diabetes mellitus

52. Antithrombotic therapy for patients with atrial fibrillation
Risk category
Recommended therapy
No risk factors
Aspirin, 81 to 325 mg daily
One moderate-risk factor
Aspirin, 81 to 325 mg daily, or warfarin (INR 2.0 to 3.0, target 2.5)
Any high-risk factor or more than 1 moderate-risk factor
Warfarin (INR 2.0 to 3.0, target 2.5)

53. Stroke Prevention in AF
Warfarin vs Placebo in
Stroke Prevention in AF
AFASAK-1
SPAF
BAATAF
CAFA
SPINAF
EAFT
ALL Trials
100% % % % %
Favors Warfarin
Favors Placebo/
Control
Warfarin reduces incidence
of stroke by about 64%
Hart R, et al. Ann Intern Med. 2007;146:

54. Antiplatelet Therapy in AF
ACTIVE-W: 6706 randomized patients; trial stopped
Clopidogrel +ASA
Warfarin
P = .0003 6 5 4
Outcome/Year (%) 3
P = .001
P = .53 2 1
Vascular Event
Stroke
Major Bleeding
ACTIVE = AF Clopidogrel Trial with Irbesartan for Prevention of Vascular Events.

55. Antiplatelet Therapy in AF
ACTIVE-A: 7554 randomized patients; median follow-up of 3.6 years
P = .01 8
Clopidogrel +ASA 7
ASA 6 5
Outcome/Year (%) 4
P<.001 3
P<.001 2 1
Vascular Event
Stroke
Major Bleeding
Active = AF Clopidogrel Trial with Irbesartan for Prevention of Vascular Events.
ACTIVE Investigators. N Engl J Med. 2009;360(20):

56. NEW ANTICOAGULANTS

57. Characteristics of new oral anticoagulants
Agent
Mechanism of Action
Dosing
Onset
Half Life
Reversibility
Clinical Development
Apixaban
Direct factor Xa inhibitor
Oral
2x daily
3 hr
12 hr No
Phase 3; ARISTOTLE, AVERROES
Rivaroxaban
1–2x daily
9 hr
Phase 3; ROCKET AF
DU 176b
1–2 hr
9–11 hr
Phase 3; ENGAGE-AF
Betrixaban
Not reported
19 hr
Phase 2; EXPLORE Xa
YM 150
Phase 2
Idrabiotaparinux
Indirect factor Xa inhibitor
Weekly
SC Injection
80–130 hr
Yes, IV avidin
Phase 3; BOREALIS–AF
Dabigatran etexilate
Direct thrombin inhibitor
12–17 hr
Phase 3; RE–LY
AZD 0837
1 hr
ATI-5923
Tecarfarin
Vitamin K antagonist
Variable
Oral 1x daily
136 hr
Yes, vitamin K
Phase 2/3; EMBRACE AC
Sobieraj-Teague M, et al. Semin Thromb Hemost. 2009;35:

58. Stroke Prevention in Atrial Fibrillation
Dabigatran etexilate vs warfarin (RE-LY)
4.00
Dabigatran 110 mg
3.50
Dabigatran 150 mg
Warfarin INR 2.0–3.0
3.00 †
Dabigatran vs warfarin
* P < Non-inferiority
**P < Non-inferiority, superiority
†P = 0.003
††P < 0.001
§ P < 0.001
2.50
Percent/Year
2.00 *
1.50 **
1.00
0.50 ††
0.00
Stroke/Systemic
Major Bleed
Intracranial
Embolism
Hemorrhage
Connolly S, et al. N Engl J Med. 2009;361:

59. AVERROES Trial E R ASA (81-324 mg daily; up to 36 mo/end of study)
Unsuitable for warfarin therapy
N= 5600 E R
Double-blind
Apixaban
(5 mg twice daily; 2.5 mg in selected patients up to 36 mo/end of study)
AVERROES, Apixaban Versus ASA to Reduce the Risk Of Stroke.

60. AVERROES: Stroke or Systemic Embolic Event
95% CI,
P<.001
0.05
ASA
Cumulative Risk
0.03
Apixaban*
0.01
0.0 3 6 9 12 18 21
Months
No. at Risk
ASA
2791
2720
2541
2124
1541
626
329
Apix
2809
2761
2567
2127
1523
617
353

61. Clinical Challenges With New Anticoagulants
No validated tests to measure anticoagulation effect
No established therapeutic range
No antidote for most agents
Assessment of compliance more difficult than with vitamin K antagonists
Potential for unknown long-term adverse events
Balancing cost against efficacy
Lack of head-to-head studies comparing new agents

62. Catheter AF Ablation Indications:
Symptomatic AF refractory or intolerant to at least 1 class I or III AAD.
Selected symptomatic patients with HF and/or reduced ejection fraction
Presence of an LA thrombus is contraindication to catheter ablation of AF
Discontinuation of anticoagulation is not an indication for ablation
CARD
Progress Indicators
9. Recognize ablation as an option for treating patients with AF. (knowledge — for PCPs and GenCards only)
Learning Objectives
3. Select the optimal treatment strategy—ie, appropriate pharmacotherapy (including antiarrhythmic therapy), ablation—for patients with AF based on patient characteristics [Progress Indicators 6, 9, 11] and make appropriate referral for ablation [Progress Indicator 10]
Instructional Objectives
9. Presented with treatment options for AF patients, participants will recognize ablation as an acceptable option
PCP
5. Select the optimal treatment strategy—ie, appropriate pharmacotherapy (including antiarrhythmic therapy), ablation—for patients with AF based on patient characteristics [Progress Indicators 6, 9, 11]

63. Common Lesions Performed in AF Ablation
A. Circumferential ablation around left and right PV antra
B. and C. Additional linear lesion sets for the roof, mitral isthmus, carinae, SVC, and cavotricuspid isthmus
D. Targeting fractionated electrograms and/or ganglionic plexi
SVC
SVC A. B.
RSPV
RSPV
LSPV
LSPV
LIPV
LIPV
RIPV
RIPV
IVC
IVC
SVC
SVC C. D.
RSPV
RSPV
LSPV
LSPV
LIPV
RIPV
LIPV
RIPV
IVC
IVC

64. Treatment of atrial fibrillation in special population

65. Management of atrial fibrillation associated with the Wolff-Parkinson-White (WPW) preexcitation syndrome
Immediate direct-current cardioversion is recommended in hemodynamically unstable patients.
Intravenous procainamide , ibutilide ,flecainide or amiodarone is recommended to restore sinus rhythm in hemodynamically stable patients.
Intravenous administration of AV nodal blocking drugs i.e. digitalis glycosides or nondihydropyridine calcium channel antagonists is not recommended.
Catheter ablation of the accessory pathway is recommended in symptomatic patients.

66. Hyperthyroidism
Administration of a beta blocker to control the rate of ventricular response .
Alternative is nondihydropyridine calcium channel antagonist (diltiazem or verapamil).
Oral anticoagulation (INR 2.0 to 3.0) is recommended in the presence of risk factors for stroke.

67. Management of atrial fibrillation during pregnancy
Digoxin, a beta blocker, or nondihydropyridine calcium channel to control the rate .
Flecainide , ibutilide , quinidine or procainamide to restore sinus rhythm in hemodynamically stable patient.
Direct-current cardioversion in hemodynamically unstable patient.
Anticoagulation in the presence of risk factor for stroke.

68. Management of atrial fibrillation in patients with pulmonary disease
Correction of hypoxemia and acidosis .
A nondihydropyridine calcium channel antagonist (diltiazem or verapamil) to control the ventricular rate.
Direct-current cardioversion in hemodynamically unstable patient.
IV flecainide may be used to restore sinus rhythm in hemodynenicall y stable patient.

69. Interruption of anticoagulation for diagnostic or therapeutic procedures
Anticoagulation may be interrupted for a period of up to 1 wk for surgical or diagnostic procedures.
In high-risk patients (particularly those with prior stroke, TIA, or systemic embolism), or when a series of procedures requires interruption of oral anticoagulant therapy for longer periods, unfractionated or low-molecular-weight heparin may be administered.

70. Summary AF is a common disease that is increasing in prevalence
For any patient with AF, decisions need to be made regarding antithrombotic therapy, rate control, and/or rhythm control
Guidelines provide recommendations for the management of patients with AF
Anticoagulation is essential in AF patients with risk markers, regardless of any restoration of SR
New agents and procedures may provide antiarrhythmic and antithrombotic options with improved outcomes for managing AF

71. Thank you for your attention!