Atrial Fibrillation

• supraventricular tachyarrhythmia with uncoordinated atrial activation

leading to ineffective atrial contraction.
• Due to spontaneous discharge by ectopic pacemaker cells in the roots
of large pulmonary veins.
Characterized by:
Irregular RR interval
Absence of distinct repeating P wave
Irregular atrial activity
Atrial rate usually 350-500 beats/min.
5 types:
• Paroxysmal
• Persistent
• Long-standing persistent
• Permanent
• Non-vulvular
Risk factors:
• HTN, Ischemic heart disease, CAD, vulvular defects, congenital heart
defects, HOCM
• Hyperthyroidism
• COPD, PE, Pneumonia
• Ethanol
• OSA
• Metabolic disorders
• idiopathic
Presentation:
• Asymptomatic-mostly

• Palpitation
• Weakness
• Reduced ability to exercise
• Fatigue
• Lightheadedness
• Dizziness
• Shortness of breath
• Chest pain
• Sxs 2* to systemic embolization/complications.
Main compications
• Systemic emboli
• Heart failure
• Tachycardia induced cardiomyopathy.
Management:
• Depends on presentation(severity of sxs and hemodynamic
instability):
Emergent
Urgent
Elective
Emergent:
• For pts presenting with symptomatic hypotension, angina, myocardial
ischemia, or heart failure.
• Only limited role of pharmacologic therapy(flecainide, propafenone,
quinidine)
• Mainstay of treatment : DC cardioversion.
Urgent:
• For hemodynamically stable, moderate to highly symptomatic
patients.
• IV AV nodal slowing agents: mainstay of treatment.
• Eg. IV beta-blockers(esmolol, metoprolol), non-dihydropyridine
calcium channel blockers(verapamil, diltiazem).
• IV Digoxin can be considered in pts with heart failure/ LV dysfunction.
Elective:
• For hemodynamically stable, asymptomatic or mildly symptomatic
patients.
Pharmacologic management: Long term mgmt
• Rate vs rhythm control:
-rate control preferred(as initial approach).
-AFFIRM and RACE-II trials: equal, perhaps better outcomes with rate
control.
-better side effect profiles of rate controlling agents
-high rate of recurrent AF with rhythm control strategy.
-high cross-over to rate-control strategy when anti-arrhythmics drugs
are used for maintenance after conversion to sinus rhythm.
-simplified medical regimen & lower cost of rate controlling agents
Rate control: ventricular rate control
• target rate: strict(resting less than 80bpm, exercise less than 110
during a 6 min walk ) vs lenient(HR less than 110bpm at anytime)

RACE II trial: lenient control is non-inferior to strict control.

Rate controlling Drugs:
• Beta blockers – atenolol, metoprolol, carvedilol, sotalol
• Non dihydropyridine calcium channel blockers – verapamil, diltiazem
• Digoxin

MOA: slowing of AV nodal conduction.

Beta blockers vs CCBs
• For beta blockers:
-low recurrence rate
-added advantages in pts with CAD, heart failure(both)
-more effective in ventricular rate control( RACE II)

• For CCBs:
-better exercise tolerance
-can be used in pts intolerant to beta blockers & pts with COPD
Rhythm control: preferred when
• Pt is symptomatic despite being in rate-controlled.
• Failure of rate control.
• Symptomatic heart failure patient
• Young individuals who need to carry out activities requiring optimal
cardiac performance.
• Afib with pre-excitation syndrome( AVN blocking- paradoxical
increase in ventricular response via accessory pathwat)
Anti-arryhthmics:
• Class Ic:
-1st line in pts with structurally normal hearts
- propafenone, flecainide
• Amiodarone: in pts with systolic heart failure and LV hypertrophy.
• Class III - sotalol, dofetelide
• Dronedarone.
Side effects profile:
• Flecainide: proarryhthmia, cardiac conduction abnormalities, renal
dysfunctions
• Quinidine: proarrhythmia/ventricular arrhythmias- torsades de
pointes; conduction defects, hypotension, CNS/GI/Immune toxicities.
Non-pharmacologic options:
• Transcatheter ablation
• AV nodal ablation and pacing- for refractory symptomatic Afib.
Prevention of complications: Thromboembolism
• Antithrombotic therapy:
-advised based on patient’s risk of developing thromboembolic events.
-calculated using CHADS2-VASc score.
• Total Score more than or equal to 2: anticoagulation strongly
recommended.
• 1: based on clinical judgement, pt based ( if more benefits-yes,
otherwise –no)
• 0: no antithrombotic therapy indicated.
Anti-coagulants in Afib:
• Warfarin( INR level 2-3 should be maintained)
• Newer agents(NOACs): apixaban, rivaroxaban, dabigatran
• Aspirin
• No evidence to support superiority of NOACs over Warfarin.
• Selection btwn them based on- cost affordability, pts renal function,
vulvular heart disease status, drug interactions.
Thank you.