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
Paroxysmal Persistent Permanent

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

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

Emergency Department

Outpatient Management

Heparinise

Warfarinise

Electrical

Chemical

Failure likely?

Flecanide

Amiodarone

Rate Control

Sotalol or Amiodarone

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 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 AF@135bpm 24 hours ago, first event Haemodynamically stable Bloods normal
Anticoagulant? Cardioversion? Maintenance? Heparin then Aspirin 75mg Flecanide 300mg Pill in pocket

Case 2
60, on carbimazole and bendroflumethiazide AF for 24 hours, otherwise normal examination All bloods normal including TFTs

Anticoagulant? Cardioversion? Maintenance?

Heparin then warfarin Electrical (not amiodarone) Bisoprolol

Case 3
28 fit and well, onset AF 3 hours ago Mild symptoms, examination normal Bloods normal

Anticoagulant? Cardioversion? Maintenance?

Heparin then aspirin Not today, return starved tomorrow Pill in pocket

Case 4
89, SOB, tachycardic, febrile, cough Raised WCC and ARF and hypokalaemia

Anticoagulant? Cardioversion? Maintenance?

Probably Not until treated Review prior to discharge

Case 5
80, hypertensive, smoker with COPD Incidental finding, symptom free Rate 110bpm

Anticoagulant? Cardioversion? Maintenance?

Warfarin No Diltiazem

Case 6
50, AF 8 hours, ejection systolic murmur Bloods normal

Anticoagulant? Cardioversion? Maintenance?

Heparin then aspirin Amiodarone Bisoprolol

Case 7
50, AF 8 hours, ejection systolic murmur Bloods normal

Anticoagulant? Cardioversion? Maintenance?

Heparin then aspirin Amiodarone Bisoprolol