1. Atrial Fibrillation

2. Outline Epidemiology Signs and Symptoms Etiology Differential Diagnosis Diagnostic Tests Classification Management

3. Epidemiology Most frequently diagnosed arrhythmia Affects 2.3 million people in the US Affects 1/136 people in the US –Columbus population 769,360 (2009) Would expect to see 5600 pts/year! Incidence increases with age

4. Signs and Symptoms Palpitations Weakness Dizziness Reduced exercise capacity Dyspnea Asymptomatic

5. Etiology/Risk Factors Structural heart disease Chronic lung disease Pneumonia Hyperthyroidism Alcohol use Pulmonary embolism HTN Pericarditis MI is a very rare cause of Afib! Think twice before doing a ROMI Key Point

6. Differential Diagnosis Narrow Complex Tachycardias –Atrial Fibrillation –Atrial Flutter –AVNRT –AVRT –Atrial tachycardia –Sinus tachycardia –Multifocal atrial tachycardia SVT is a category, not a diagnosis!

7. Classification Paroxysmal: terminates in < 7 days Persistent: fails to terminate within 7 days Permanent: > 1 year Lone: Individuals without structural heart disease, < 60 yrs old

8. Diagnostic Testing: EKG Narrow Complex Irregularly Irregular Rapid Ventricular Rate

9. Diagnostic Testing: TTE To assess for structural heart disease –EF –Wall motion –Dilation/Hypertrophy –Size of right and left atrium –Valvular disease –Pericardial disease

10. Chest X-Ray Look for emphasema/COPD Cardiac borders Pneumonia Rush Center for Congenital and Structural Heart Disease

11. Management Rate Control Rhythm Control Anticoagulation Unstable patients

12. Rate Control Why is rate control important? –Ischemia, MI, hypotension can occur –Long term: Cardiomyopathy Goals –Rest HR < 80 bpm –24 Hour (Tele/Holter) < 100 bpm average –HR < 110 in 6 minute walk Key Point

13. Rate Control (con’t) Medications –Metoprolol / Esmolol: IV or Oral –Diltiazem: IV or Oral –Verapamil: Oral Only –Digoxin: Patients with hypotension –Amiodarone: Also for rhythm control

14. Rhythm Control Indications –Symptoms of a-fib persistent –To avoid long term anticoagulation –Bleeding risk –Personal preferenance

15. Rhythm Control (con’t) Synchronized DC cardioversion –Emergencies/Hemodynamic instability –Greater efficacy than medications Pharmacologic cardioversion –If AF < 7days – dofetilide, flecainide, ibutilide, propaferone or amiodarone –If AF > 7 day – dofetilide or amiodarone

16. Rate or Rhythm Control? Affirm Study: Rate versus rhythm control –No difference in incidence of stroke –Trend towards lower mortality in the rate control group –See article –This is STILL a controversial topic!

17. Anticoagulation and Cardioversion Afib < 48 hours: –Cardioversion (CV) –No anticoagulation indicated Afib > 48 hours: –Anticoagulate for 3-4 weeks before CV –OR get TEE –Anticoagulate for 1 month after CV

18. Anticoagulation – Long Term Risk of CVA determined by CHADS2 score (CHF, HTN, >75, DM, Previous CVA x 2) ScoreAnnual Stroke Risk % 01.9 12.8 24.0 35.9 48.5 512.5 618.2 Key Points Most patients, can wait 48 hours before starting 0-1 probably don’t need anticoagulation 5-6 should be bridged with heparin/LMWH

19. Management – Unstable Unstable: A-fib associated with Hypotension Synchronized electric Cardioversion immediately Key Point

20. Key Points MI is a rare CAUSE of a-fib Rate control must be achieved during exercise, not just at rest Not every patients needs to bridge with heparin Unstable patients should immediately be cardioverted

21. Questions?