1. #1009 Evaluation & Management of Atrial Fibrillation November 16 to 19 Stephen F. Schaal, MD Professor of Internal Medicine Division of Cardiology The Ohio State University Medical Center Robert Hoover, MD Assistant Professor of Internal Medicine Division of Cardiology The Ohio State University Medical Center

2. 1 Stephen F. Schaal, MD Professor of Internal Medicine Division of Cardiology The Ohio State University Medical Center

3. Profile Mrs. Greer 73 year old female Presented with palpatations Evaluation Exercise study - PVC’s R ate dependent LBBB Cardiac catheterization Findings Normal coronary arteries Mrs. Greer 73 year old female Presented with palpatations Evaluation Exercise study - PVC’s R ate dependent LBBB Cardiac catheterization Findings Normal coronary arteries 2

4. Profile Mrs. Greer MVP; mild mitral regurgitation Normal left ventricular function Very small ASD Side effects Palpatations / trachycardia Atrial flutter-sotalol started Weight gain Mrs. Greer MVP; mild mitral regurgitation Normal left ventricular function Very small ASD Side effects Palpatations / trachycardia Atrial flutter-sotalol started Weight gain 2A

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8. Atrial Fibrillation Common Etiologies Cardiac Vavular heart disease - Mitral stenosis insufficiency - Mitral valve prolapse - Aortic valve disease - Tricuspid valve disease Hypertension cardiovascular disease Cardiomyopathy Ischemic heart disease Pericardial disease Conduction system disease (“lone”) Common Etiologies Cardiac Vavular heart disease - Mitral stenosis insufficiency - Mitral valve prolapse - Aortic valve disease - Tricuspid valve disease Hypertension cardiovascular disease Cardiomyopathy Ischemic heart disease Pericardial disease Conduction system disease (“lone”) Endocrine Hyper, hypothyroidism Pheochromocytoma Pulmonary Pulmonary emboli Obstructive pulmonary disease Metabolic / Drug Acute alcohol Cocaine Theophylline, catecholamines Endocrine Hyper, hypothyroidism Pheochromocytoma Pulmonary Pulmonary emboli Obstructive pulmonary disease Metabolic / Drug Acute alcohol Cocaine Theophylline, catecholamines 6

9. Electrophysiologic Substrate For Atrial Fibrillation Disparate atrial ERPs Fragmented conduction Atrial stretch Autonomic dysfunction Disparate atrial ERPs Fragmented conduction Atrial stretch Autonomic dysfunction 7

10. Evaluation Of Atrial Fibrillation History - Duration - Symptoms - Presence of heart disease - Drugs, toxins - State of anticoagulation - Other disease Physical Examination - Cardiomegaly - Valvular disease - Pericardial disease - Thyroid disease - Other ECG Chest x-ray Echocardiogram History - Duration - Symptoms - Presence of heart disease - Drugs, toxins - State of anticoagulation - Other disease Physical Examination - Cardiomegaly - Valvular disease - Pericardial disease - Thyroid disease - Other ECG Chest x-ray Echocardiogram 8

11. Consequence Of Atrial Fibrillation Hemodynamic compromise - Atrial enlargement and disorganized atrial depolarization atrial dysfunction - Varying atrial and ventricular rate AV valve dysfunction - Inappropriate acceleration of heart rate with exercise, stress Result: possible fatigue, dyspnea, CHF, angina Electrophysiologic compromise - Atrial fibrillation begets atrial fibrillation Thromboembolic compromise - Stroke - Other systemic or pulmonic emboli Hemodynamic compromise - Atrial enlargement and disorganized atrial depolarization atrial dysfunction - Varying atrial and ventricular rate AV valve dysfunction - Inappropriate acceleration of heart rate with exercise, stress Result: possible fatigue, dyspnea, CHF, angina Electrophysiologic compromise - Atrial fibrillation begets atrial fibrillation Thromboembolic compromise - Stroke - Other systemic or pulmonic emboli 9

12. Stroke Risk Factors In Atrial Fibrillation Age (Framingham) Rheumatic heart disease (Framingham) Poor left ventricular function or recent CHF (SPAF) Enlarged left atrium (SPAF) Previous myocardial infarction (AFASAK) Hypertension (SPAF) History of previous thromboembolic event (SPAF) Presence of left atrial thrombus, atrial contrast, or reduced atrial appendage flow (by TEE) Age (Framingham) Rheumatic heart disease (Framingham) Poor left ventricular function or recent CHF (SPAF) Enlarged left atrium (SPAF) Previous myocardial infarction (AFASAK) Hypertension (SPAF) History of previous thromboembolic event (SPAF) Presence of left atrial thrombus, atrial contrast, or reduced atrial appendage flow (by TEE) 10

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15. Considerations For Maintaining Normal Sinus Rhythm Physiologic control of ventricular rate Atrial contribution to cardiac output Better exercise tolerance Thromboembolic risk probably reduced Risks of long-term anticoagulation therapy may be avoided, especially if warfarin contraindicated Tachycardia-induced cardiomyopathy controlled Occasional AF recurrence is not drug inefficacy Physiologic control of ventricular rate Atrial contribution to cardiac output Better exercise tolerance Thromboembolic risk probably reduced Risks of long-term anticoagulation therapy may be avoided, especially if warfarin contraindicated Tachycardia-induced cardiomyopathy controlled Occasional AF recurrence is not drug inefficacy 13

16. Recovery Of Atrial Mechanical Function After Restoration Of Sinus Rhythm Technique: doppler atrial filling wave with peak velocity 0.5 m / s (Manning et al) Cardioversion, drug, spontaneous conversions Patients (%) Recovery Interval 20 within 6 hours >50 by 1st day >75 by 1st week 92 (drug or spontaneous) by day 3 Technique: doppler atrial filling wave with peak velocity 0.5 m / s (Manning et al) Cardioversion, drug, spontaneous conversions Patients (%) Recovery Interval 20 within 6 hours >50 by 1st day >75 by 1st week 92 (drug or spontaneous) by day 3 14

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18. Vagally Mediated AF (A Form Of Lone AF) Occurs during high vagal tone - Postprandial - Sleep - Rest - Post exercise Not related to sick sinus syndrome Preceded by slowing of heart rate Digitalis should be avoided Rarely progresses to permanent AF Rarely a pure syndrome Occurs during high vagal tone - Postprandial - Sleep - Rest - Post exercise Not related to sick sinus syndrome Preceded by slowing of heart rate Digitalis should be avoided Rarely progresses to permanent AF Rarely a pure syndrome 16

19. Summary Mrs. Greer Diagnosis - Mitral valve prolapse - Left atrial enlargement - Atrial flutter / atrial fibrillation Mrs. Greer Diagnosis - Mitral valve prolapse - Left atrial enlargement - Atrial flutter / atrial fibrillation 17

20. Summary Mrs. Greer Treatment - Increased amiodarone - Brady / tachy with fatigue, junctional rhythm - AV sequential pace - AV node ablation - Repeat ablation Prognosis: Good Mrs. Greer Treatment - Increased amiodarone - Brady / tachy with fatigue, junctional rhythm - AV sequential pace - AV node ablation - Repeat ablation Prognosis: Good 17A

21. Robert Hoover, MD Assistant Professor of Internal Medicine Division of Cardiology The Ohio State University Medical Center 18

22. Therapeutic Approaches To Atrial Fibrillation Anticoagulation Antiarrhythmic suppression Control of ventricular response - Pharmacologic - Catheter modification / ablation of AV node Curative procedures - Surgery (maze) - Catheter ablation Anticoagulation Antiarrhythmic suppression Control of ventricular response - Pharmacologic - Catheter modification / ablation of AV node Curative procedures - Surgery (maze) - Catheter ablation 19

23. Current Recommendations For Anticoagulation Therapy For Atrial Fibrillation INR 2.0 - 3.0 for appropriate patients or Warfarin (INR 2.0 - 3.0) or ASA 325 mg / day in patients without clinical or echocardiographic risk factors INR 2.0 - 3.0 for appropriate patients or Warfarin (INR 2.0 - 3.0) or ASA 325 mg / day in patients without clinical or echocardiographic risk factors 20

24. Role Of Echo In Atrial Fibrillation Identify structural heart disease Identify LVH Identify increasing LA size Detect “smoke” Detect clot in LA Identify structural heart disease Identify LVH Identify increasing LA size Detect “smoke” Detect clot in LA 21

25. Role Of TEE In Atrial Fibrillation Transesophageal echo is more sensitive (92%) and specific (98%) for detecting atrial clot Thromboembolic event is presumably due to left atrial clot Most clots are in left atrial appendage but poorly visualized by transthoracic surface echo Transesophageal echo is more sensitive (92%) and specific (98%) for detecting atrial clot Thromboembolic event is presumably due to left atrial clot Most clots are in left atrial appendage but poorly visualized by transthoracic surface echo 22

26. Rationale For Precardioversion TEE Absence of clot on TEE may obviate need for anticoagulation Avoiding delay necessary for prolonged anticoagulation prior to cardioversion increases likelihood of successful cardioversion and maintenance of normal sinus rhythm Absence of clot on TEE may obviate need for anticoagulation Avoiding delay necessary for prolonged anticoagulation prior to cardioversion increases likelihood of successful cardioversion and maintenance of normal sinus rhythm 23

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35. Atrial Fibrillation: Areas Of Research AFFIRM study - National Heart Institutes atrial fibrillation study - Heart rate control and anticoagulation vs. rhythm control with antiarrhythmic drugs Patient-activated or automatic atrial defibrillator Dual-site and biatrial pacing Atrial pacing therapies for AF prevention Catheter ablation therapies for AF - Catheter “maze” procedure - Ablation for “focal” AF AFFIRM study - National Heart Institutes atrial fibrillation study - Heart rate control and anticoagulation vs. rhythm control with antiarrhythmic drugs Patient-activated or automatic atrial defibrillator Dual-site and biatrial pacing Atrial pacing therapies for AF prevention Catheter ablation therapies for AF - Catheter “maze” procedure - Ablation for “focal” AF 32

36. #1010 Asthma Update November 30 to December 3 Philip E. Korenblat, MD Professor of Clinical Medicine Washington University School of Medicine St. Louis, Missouri Elizabeth Allen, MD Associate Professor of Clinical Pediatrics Section of Pulmonary Medicine Children’s Hospital & The Ohio State University Medical Center OMEN is OFF Thanksgiving Week Our NEXT PROGRAM is: