1. Atrial Fibrillation
Dr Nidhi Bhargava
8/10/13

2. Most Common sustained clinical arrhythmia
Incidence rises with age- >5% over the age 65-75

3. Risk factors for AF Hypertension- accounts for 14% of AF in population
Heart failure
Male sex
Diabetes
Valvular MI
LVH
LVSD
Left atrial dilatation
Lone AF- with no structural or functional heart disease- 15%

4. Types of AF
Paroxysmal or recurrent (intermittent and self terminating)
35-66% of all AF cases peak prevalence 50-69yrs
At least a quarter may go progress to permanent AF
Persistent (does not terminate spontaneously but may be effectively cardioverted)
Permanent ( no longer reversible or reverses for brief interval only)

6. Effects of AF Haemodynamic effects
Loss of atrial contraction and AV synchrony
Rapid ventricular rate
Irregular ventricular rate

7. Effects of AF
Symptoms
Palpitations
Breathlessness
Chest pain

8. Effects of AF Thromboembolism
Valvular AF -more so in pts.. with MS and AF (6% per year)
Non Valvular AF- 4-5 times increased risk of stroke overall
Further increased risk if
Previous stroke or TIA (20x increased risk)
Age >65, Hypertension and diabetes
CAD, LV dysfunction and Left atrial dilatation
<65 yrs. risk 1% per annum

9. Effects of AF Mortality- doubled in both sexes
Increased risk of stroke 4-5 fold increase- further increase with age from 1.5% in sixth decade to 23.5% in the ninth decade

11. Treatment Restoration of sinus rhythm Pharmacological cardioversion
Electrical cardioversion
External
Internal

12. Treatment Maintenance of sinus rhythm Ventricular Rate Control
Drugs
DDD pacing
Ablation of AF triggers
Surgery for AF
Ventricular Rate Control
Anticoagulation

13. Treatment Cardioversion (pharmacological and electrical)
Electrical cardioversion
External and Internal
External- under GA, success rate 65-90%, J
Internal- under sedation- percutaneous electrode- success rate 90%
Pharmacological cardioversion
Most effective if administered within 24 hrs. of onset
Flecainide most effective %
Others include amiodarone , sotalol, propafenone
Less effective in chronic AF- Amiodarone most effective
At least 4 weeks of full anticoagulation
Anticoagulation to e maintained for 4 weeks after successful cardioversion

14. Treatment Maintenance of Sinus rhythm Drugs Pacing
Flecainde and Propafenone (Class 1c)
Sotalol better then propafenone
Amiodarone – most effective but multiple side effects
Beta blockers- no date available
Digoxin- no effect
Pacing
DDD pacing- reduce AF paroxysms
Continuous atrial pacing-dual site or biatrial

15. Treatment Focal Ablation
Targets AF initiating foci located in proximal pulmonary veins
Radiofrequency energy delivered
Used for pts. with paroxysmal AF
Pts. with chronic AF but can be successfully cardioverted at least for few seconds
Under LA
Success rate 70% in PAF and 50% in chronic AF

16. Treatment Surgery for AF-Maze operation Ventricular rate control
AV node ablation
Drugs
Digoxin- not negative inotropic but less effective
Diltiazem, verapamil and beta blockers- more effective but negatively inotropic

22. Case histories
A 67 years old female with no risk factors presents with palpitations
A 77 years old male with no risk factors is found to be in AF on routine examination
A 98 years old male with AF on warfarin presents with haematuria and subsequently diagnosed with Ca bladder
A 79 year old female with AF rate /min, on warfarin and digoxin, asthmatic and has severe reaction to verapamil-treatment options
A 64 years old diabetic is in AF on routine examination