Atrial Fibrillation Current Management Strategies

Overview 25% will develop AF during lifetime 4% above 60 8% above 80 Total sufferers to double by 2050 Doubles annual risk of death (Framingham) 5% annual risk of stroke

Definitions Paroxysmal AF – Under 7 days – 2 or more episodes Persistent AF – 7 days to 1 year Permanent AF – Over 1 year with/without intervention – Accepted for rate control

Pathophysiology Supraventricular ectopic focus with permissive atrial substrate Younger Myocytes in pulmonary veins Drugs and alcohol Metabolic abnormalities Electrolyte abnormalities Sepsis Older LVH/aortic stenosis Atrial ischaemia and IHD Mitral stenosis/incompetence Hypertension Catecholamine drive Sepsis

Two Considerations Reduce ventricular rate – Cardiovert – Slow Prevent thromboembolism – Cardiovert – Anticoagulate

Treatment Strategies Rhythm Control Younger First presentation Underlying cause treated Symptomatic Heart Failure Rate Control Older Coronary artery disease Contraindications to cardioversion Previous failure ParoxysmalPermanentPersistent Rhythm ControlRate Control Failure Symptoms Persist

Rhythm Control – Paroxysmal AF All need assessment for anticoagulation May need cardioversion (but aim to avoid) Pill in pocket may be appropriate (flecanide) Standard beta-blocker first line (bisoprolol) If failure: – CAD – Sotalol – LVD – Amiodarone

Rhythm control – Persistent AF Onset < 48 hours Electrical Outpatient Management Emergency Department Chemical AmiodaroneFlecanide Heparinise Sotalol or Amiodarone Failure likely? Warfarinise Rate Control

Rate control – Persistent or Permanent All patients need assessment for anticoagulation Aim for rate under 100 (may need nothing) Beta-blocker of calcium channel antagonist Add digoxin if further control necessary

Thromboembolism Ineffective atrial contraction Venous pooling in atrial appendage Embolism

CHAD2Vasc Congestive Cardiac Failure Hypertension Age > 75 (2) > 65 (1) Stroke/TIA/DVT/PE (2) Vascular disease Diabetes Female 0 – Low risk 1 – Moderate risk > 2 high risk

European Society of Cardiology High Risk CVA TIA VTE High Risk CVA TIA VTE Medium Risk > 75 HTN EF < 35% DM Medium Risk > 75 HTN EF < 35% DM No Risk Warfarin Aspirin

Ablation/MAZE procedure 1:1000 death 1:50 complications 60% success

Case 1 40, fit and healthy, normal ET, normal resting ECG Onset 24 hours ago, first event Haemodynamically stable Bloods normal Anticoagulant? Maintenance? Cardioversion? Heparin then Aspirin 75mg Pill in pocket Flecanide 300mg

Case 2 60, on carbimazole and bendroflumethiazide AF for 24 hours, otherwise normal examination All bloods normal including TFTs Anticoagulant? Maintenance? Cardioversion? Heparin then warfarin Bisoprolol Electrical (not amiodarone)

Case 3 28 fit and well, onset AF 3 hours ago Mild symptoms, examination normal Bloods normal Anticoagulant? Maintenance? Cardioversion? Heparin then aspirin Pill in pocket Not today, return starved tomorrow

Case 4 89, SOB, tachycardic, febrile, cough Raised WCC and ARF and hypokalaemia Anticoagulant? Maintenance? Cardioversion? Probably Review prior to discharge Not until treated

Case 5 80, hypertensive, smoker with COPD Incidental finding, symptom free Rate 110bpm Anticoagulant? Maintenance? Cardioversion? Warfarin Diltiazem No

Case 6 50, AF 8 hours, ejection systolic murmur Bloods normal Anticoagulant? Maintenance? Cardioversion? Heparin then aspirin Bisoprolol Amiodarone

Case 7 50, AF 8 hours, ejection systolic murmur Bloods normal Anticoagulant? Maintenance? Cardioversion? Heparin then aspirin Bisoprolol Amiodarone