NILOFAR RAHMAN, MD AMIT KUMAR, MD

DEFINITION  A SVT with uncoordinated atrial activation with constant deterioration of atrial mechanical function  On EKGs it is defined by replacement of consistent P waves with rapid oscillations that vary in size, shape and timing ass. With an irregular RVR when AV conduction is intact.

CLASSIFICATION  PAROXYSMAL: Self terminates< 7 days, usu, within 24 hrs.  PERSISTENT: > 7 days, terminate spontaneously or by cardioversion  PERMANENT : > 1 YR, CV attempted or failed  LONE : Without any structural heart disease

 HTN: 1.4 fold increase risk  CHD: when complicated by acute MI or heart failure  CASS trial: RR was 1.98 in 7 yrs  VALVULAR HEART DISEASE:  MS, MR, TR: 70% RISK  MS, MR: 52%  ISOLATED MS: 29%  HYPERTROPHIC CMP:  CONGENITAL HEART DISEASE  OTHERS: hyperthyroidism, PE, COPD, lupus myocarditis  OSA: reduced reccurence with treatment

CLINICAL MANIFESTATIONS  SYMPTOMATIC OR ASX EVEN IN SAME PT.  PALPITATION/CP/DYSPNEA/FATIGUE/LIGHTHEADEDNESS/SYNCOPE  EMBOLIC COMPLIC. OR HEART FAILURE  POLYURIA: ANP  ASS. RVR- CMP

 H&P:  EKG: verify AF  CXR: lungs, vasculature and cardiac outline  ECHO  TTE: size and function of chambers, valvular heart diseases  TEE: thrombi in left atrium  TSH  ADDITIONAL TESTING:  EXERCISE TEST  HOLTER/EVENT MONITOR

GENERAL PRINCIPLES OF TREATMENT RHYTHM CONTROL CONVERSION TO NSR MAINTAINENCE RATE CONTROL MEDICATION RADIOFREQUENCY ABLATION CHOOSING B/W RATE AND RHYTHM CONTROL PREVENTION OF SYSTEMIC EMBOLIZATION

RATE VS. RHYTHM CONTROL  AFFIRM AND RACE TRIALS: 2 CONCLUSIONS-  Embolic event occur in equal frequency  lower incidence of primary end point with rate control strategy

RATE CONTROL Beta blockers Calcium channel blockers Digoxin GOALS: HR<80 bpm, 24 hr. Holter average <100 bpm, HR < 110 bpm in 6 min. walk Non pharmacologic method: radiofrequency ablation and pacemaker implantation

RHYTHM CONTROL  PHARMACOLOGIC  DIRECT CURRENT CARDIOVERSION  Anticoagulation for 3-4 weeks before CV  Anticoag for 1 month after CV  usu done in hemodynamically unstable pts.  success rate is 75-93%, inversely related to atrial size and duration

Maintenance of NSR:  20-30% maintain NSR > 1 yr. w/o antiarrythmics  duration of <1 yr, atrial size < 4 cm.  reversible causes  Amiodarone is known to be most effective  CTAF and AFFIRM trials  Flecainide and propefenone in those without heart disease

 RISK OF STROKE IS 3-5% WITHOUT ANTICOAGULATION  CHADS2 SCORE  SCORE OF 0: ASA  SCORE 1-2: ASA/WARFARIN  SCORE > 2: WARFARIN, INR GOAL 2-3

 APPROVED IN 10/10  RE-LY TRIAL EVALUATED SAFETY OF 2 DOSES RESULTS:  Rate of stroke was lesser  High dose - more effective than warfarin  Risk of bleeding was lesser in low dose  All-cause mortality was reduced

DISADVANTAGES  Twice dosing  High cost  Lack of an antidote  Dose adjustment for those with CKD  lack of long term safety data

THANK YOU