2 1. bradyarrhythmias 2. tachyarrhythmias (AF)

AF accounts for 1/3 of all patient discharges with arrhythmia as the principal diagnosis
SVT 6%
Unspecifie d

PVCs 6% AFl 4% SSS 9%

AF 34%

AV Block 8% SCD 3% VT 10% VF 2%

Data source: Baily D. J Am Coll Cardiol1992;19(3):41A


  

3 pacemaker (cardiac (cardiac impulse) conducting cell pacemaker myocardium myocardium

  

P wave = Atrial depolarization QRS = Ventricular depolarization T wave = Ventricular repolarization

conducting system conducting system

conducting system conducting system

 arrhythmia


 sinus  atrial  A-V

junction  ventricular

arrhythmia

(Abnormal (Abnormal impulse generation) automaticity (Impulse conduction abnormality)

 arrhythmias arrhythmias
1.

Atrial flutter :rate 250-350, P:Q = 2:1 , 250-350, 3:1 , 4:1 Atrial fibrillation :total irregularity, rate > atrial flutter Premature ventricular contraction(PVC) :abnormal QRS Ventricular fibrillation: rate > 200 fibrillation:

2.

3.

4.

Atrial flutter

Atrial fibrillation

AF P wave fibrillatory wave

Patterns of Atrial Fibrillation

First detected

Paroxysmal (self-terminating)

Persistent (not self-terminating)

Permanent (accepted)

Prevalence
 0.5

-1% of general population 2 -4% : >60 year-old group > 8% : > 80 year-old group

Men VS Women  White VS Black



(cardiac causes) 1. valvular heart diseases mitral valve stenosis 2. non-valvular heart diseases A.
Hypertensive heart disease Ischemic heart disease Sick sinus syndrome Pericarditis Cardiomyopathy

Atrial fibrillation
atrium depolarization 400
atrium AV node ventricle ventricle

preload cardiac output

 AF
1.

Hemodynamics

2.

3.


1.

2. 3.

Prevention of thromboembolism Rate Control Rhythm control

Prevention of thromboembolism A. Acute management

cardioversion 3 1. AF 48 2. AF 48 thromboembolism 3. cardioversion

1.

warfarin

AF 48
cardioversion

heparin INR

anticoagulate IV unfractionated hep therapeutic range heparin transesophageal echocardiogram (TE warfarin 3 atrialthrombus cardioversion cardioversion warfarin 4 warfarin 4

 48 .


cardioversion Warfarin thromboembolism 7% cardioversion hypocontractile atrial appendage 3 warfarin 4 thromboembollism anticoagulant GI Bledding cardioversion cardioversion

AF

2. AF thromboembolism

48

anticoagulation cardioversion anticoagulate IV unfractionated heparin LMWH thromboembolism TEE thrombus cardioversion

AFib < 48
AFib

 

Weigner 357 250 spontaneous conversion 107 cardioversion DC or pharmacological conversion emboli 3 ( 0.8%) cardioversion AFib < 48

Electrical and Mechanical remodeling Thromboembolism

Thromboembolism DC or Pharmacologic conversion incidence AFib < 48 Anticoagulant Embolism

 

AFib < 48

AFib + rheumatic mitral valve disease AFib + spontaneous echo contrast in left atrium or left atrial appendage( ) AFib + prior thromboembolism

Comparision of electrical and chemical cardioversion DC Chemical

Success rate Sedation or Anesthesia NPO cardioversion > 90 % Yes cardioversion 40 % No

Contraindicatio n

No Yes (Except when hemodynamical ly unstable) Duration > 1

Comparision of electrical and chemical cardioversion DC Chemical

cardioversion Contraind ation cardioversion Hemodynamic instability Acute coronary ischemia Marked LV hypertrophy Marked LV failure Hypokalemia Hypomagnesemia Currently on an

Comparision of electrical and chemical cardioversion DC cardioversion Chemical

cardioversion Comment Consider adding an antiarrhythmic if * Initial DC cardioversion is unsuccessful * High likelihood of recurrence of atrial fibrillation after cardioversion Some institutions administer a single bolus of 5000

3. cardioversion angina heart failure

IV unfractionated heparin cardioversion warfarin 4

 B.

Chronic management thromboembolic complication persistent AF permanent AF cardioversion cardioversion thromboembolic stroke

CHADS2 Score


Score of 0: at low risk and may be treated with ASA alone or observation Score of 1-2: can weigh benefits/risks of warfarin vs ASA to decide Score of > 3: at greatest risk and should be treated with chronic adjusted warfarin unless there is a contraindication

1. Prevention of thromboembolism 2. Control of Ventricular Rate 3. Rhythm control

2. Control of Ventricular Rate

100 20

control agents

Rate

 

beta blocker , CCB , digoxin Beta blockers or CCB Beta blockers HR Cardioprotective effect COPD or asthma Beta blocker agent CHF + AF dose HR HF CCB second line rate control agent beta blocker CCB

HR

HR Heart failure Tachycardia induced cardiomyopathy Resting HR 80 90 Exercise HR = ( 220 age ) x 0.7 and should not be reached during light exercise 6 HR 100

AFFIRM/RACE HR NSR NSR HR NSR thromboembolism bleeding Anticoagulant

A Fib

 1 AFib hyperthyroidism, Worsening mitral valve disease, uncontrolled hypertension, Hypokalemia, Fever, anemia, and CHF DRP  2


Antiarrhythmia drug therapy fails

3 AFib  AFib < 1 1 3 short duration < 30 60 Extra dose  Recurrence AFib > 24 48 cardioversion 4

Antiarrhythmia drug therapy fails

NSR ( Spontaneous conversion to sinus rhythm) Cardioversion 24 spontaneous conversion to sinus rhythm 48 % observed 24 cardioversion cardioversion

AFib < 48

Control of Ventricular Rate

1. Calcium channel blockers 2. Beta-blocker 3. Digitalis 4. Amiodaron

Drug BB

drug of choice AF ischemic heart disease, acute thyrotoxicosis high sympathetic tone ( AF post-operative AF) NDHP CCB

systolic heart failure EF < 40% Asthma COPD

Drug NDHP CCBs

( IV impaired left betablocker IV ventricular function nondihydropyridine (EF< 40%) CCB ) systolic heart failure COPD asthma

Drug Digoxi n

impaired left ventricular function decompensated heart failure

digoxin ventricular arrhythmia atrioventricular block verapmil amiodarone digoxin

Drug

Amioda heart failure rone

accessory pathway (WPW syndrome)

impaired left ventricular function

amiodarone

3. Rhythm control
1. Pharmacological cardioversion 2. Direct current cardioversion 3. Maintain sinus rhytm

Flecainide Propafenone Amiodarone

Pharmacological cardioversion
3

AF
AF

ACEI ARB AF ACEI ARB

RAAS


AF  AF  AF warfarin digoxin


beta blocker

Beta blocker ventricular arrhythmias class sudden death ventricular tachycardia ventricular fibrillation class II ventricular arrhythmia


 

Beta blocker AF

systolic heart failure or EF < 40 % Decompensated heart failure First choice AF + AMI, AF + acute thyrotoxicosis , AF + high sympathetic tone AF AFFIRM BBB Ventricular

digoxin AFib


HR


AF + impaired left ventricular function or AF + decompensate

1 Onset 2 6 8 maximum effect 2 prolong AF episodes PAF 72 relative risk of longer AF episodes associated with digoxin 4.3 compared with other negative dromotropic agents ( P< 0.01 )

first line

Digoxin AFib


high sympathetic tone Loading dose 10 mcg/kg 3 ( 1/2,1/4,1/4 ) 6 maintenance dose maintenance dose renal function loading dose HR CCB and BBB HR CCB or BBB CCB or

First degree AV block



AV node 0.2

) EKG PR interval 5 ( > 0.2 ) ventricle CO

Digoxin


enzyme Na K ATPase Na ion ( Na K ) Ca ion Na ion

Exclusion criteria used in trials evaluating the Efficacy and safety or warfarin in patients with Nonvalvular heart diisease
   

 

Active bleeding Active peptic ulcer disease Known coagulation defects Thrombocytopenia (platelet less than 50,000) or platelet dysfunction Recent hemorrhagic stroke Non compliant or unreliable patient

Exclusion criteria used in trials evaluating the Efficacy and safety or warfarin in patients with Nonvalvular heart disease
  

 

 

Psychologically or socially unsuitable patient Dementia o severe cognitive impairment History of falls ( three within the previous year or recurrent, injurious falls) Excessive alcohol intake Uncontrolled hypertension ( greater than 180 / 100 ) Acute stroke warfarin Daily use of NSAID Planned invasive procedure or major

Risk Factor for bleeding for long term use of warfarin

  

  

   

History of significant bleeding Known coagulation defects Thrombocytopenia ( platelet less than 50,000 ) or platelet dusfunction Recent hemorrhagic stroke Uncontrolled hypertension ( greater than 180/100) Daily use of any platelet inhibitor ( ASA, Clopidogrel,NSAIDs,herbal supplements Excessive alcohol intake Recurrent falls Inconsistent compliance Erratic INRS


 

warfarin cardioversion

Anticoagulant heparin + warfarin Heparin INR 2 warfarin 3 4 NSR cardioversion ( unstable hemodynamic) Heparin thrombus atrium Transesophageal echocardiogram (TEE) thrombus cardioversion warfarin 4

Non dihydropyridine calcium channel blocker

 

Verapamil and diltiazem ventricular rate ACC/AHA/ESC 2 impaired left ventricular function EF < 40 % systolic heart failure negative inotropic effect decompensated heart failure beta blocker Asthma or COPD HR < 100 20% baseline

Amiodarone
 

AV node

 

Heart failure AF Accessory pathway ( WPW syndrome )

 Amiodarone rhythm control

   

Structural heart disease Left ventricular hypertrophy Coronary artery disease Impaired left ventricular function heart failure

 amiodarone
     

Bradycardia ( cardiac arrest ) Hypotension Visual disturbance Thyroid abnormality Nausea Pulmonary toxicity