European Heart Journal (2006):27, Joint ESC/ACC/AHA Guidelines 2006 Developed in collaboration with the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS) Atrial Fibrillation (Management of Patients with)

Joint ESC/ACC/AHA Guidelines Supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of mechanical function Supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of mechanical function Most common sustained cardiac rhythm disturbance Most common sustained cardiac rhythm disturbance –2.3 mill. N.America, 4.5 mill EU: parox AF/ persist AF Prevalence increases with age Prevalence increases with age Often associated with structural heart disease Often associated with structural heart disease Acute temp causes: etoh, hyperthyr, surgery, peri-/myocarditis, MI, PE, pulm.dis, metabolic,… Acute temp causes: etoh, hyperthyr, surgery, peri-/myocarditis, MI, PE, pulm.dis, metabolic,… Haemodynamic impairment and thromboembolic events result in significant morbidity, mortality, cost Haemodynamic impairment and thromboembolic events result in significant morbidity, mortality, cost Atrial Fibrillation

Joint ESC/ACC/AHA Guidelines Patterns of Atrial Fibrillation

Joint ESC/ACC/AHA Guidelines Management strategies Rate control Rate control –no commitment to restore or maintain SR –beta bl., diltiazem, verapamil; HF: digox; acc.pw: amiodar Prevention of thromboembolism Prevention of thromboembolism –antithrombotic therapy recommended to all AF, exc.lone AF or CI –agent based upon risk of stroke/bleeding Correction of rhythm disturbance (?) Correction of rhythm disturbance (?) –restoration and/or maintenance of sinus rhythm –also requires attention to rate control

Joint ESC/ACC/AHA Guidelines Prevention of thromboembolism

Joint ESC/ACC/AHA Guidelines Cardioversion of AF: recommendations AF + rapid VR + HD-instability: DC-cardioversion AF + rapid VR + HD-instability: DC-cardioversion AF + rapid VR + angina, HT, HF + no prompt response to pharm. Measures: DC-cardioversion AF + rapid VR + angina, HT, HF + no prompt response to pharm. Measures: DC-cardioversion rhythm control (pharmacological and DC-cardioversion !): rhythm control (pharmacological and DC-cardioversion !): –< 48h duration, anticoagulation before/after according risk –> 48h/unknown duration: antico 3w prior to and 4w after antico 3w prior to and 4w after TOE: no thrombus, antico during and 4w after TOE: no thrombus, antico during and 4w after consider AAD-pretreatment (if safe!) consider AAD-pretreatment (if safe!) Interruption of antico for procedures: Interruption of antico for procedures: –antico may be interrupted for up to 1 wk without heparin-subst –mechanical prosthetic valves + prior stroke/TIA: (lmw)heparin subst