1. Management of Atrial Fibrillation ♦ Assess the need to convert to sinus rhythm
Causes of Atrial Fibrillation Physical Exam
Cardiac ♦ Valvular dz – MR, MS ♦ Sick sinus syndrome ♦ confirm AF (4 signs)
♦ IHD ♦ Post-cardiac surgery o IR IR pulse
♦ HPT ♦ Peri-/myo-carditis o Single flicker JVP - absence of ‘a’ wave
♦ Post MI ♦ Pre-excitation syndrome o pulse deficit
♦ CCF ♦ Acute pul. Embolism o varying loudness of 1st heart sound
♦ ASD ♦ Lone AF (no known ♦ signs of underlying causes of AF– BP, goiter and signs of thyrotoxicosis,
♦ Cardiomyopathy etiology or structural heart auscultation for murmurs (MR/MS)
dz. Dx of exclusion)
♦ complications – CCF, previous stroke
Non-Cardiac ♦ Hyperthyroidism ♦ DM
♦ Sepsis esp pneumonia ♦ Alcohol
Investigations
ECG ♦ to document AF, any evidence of MI, LVH/LAH
Morbidities of AF CXR ♦ chamber size, heart failure
♦ ↓ cardiac output – malaise and effort intolerance
FBC
♦ aggravation of MI and heart failure
U/E
♦ ↑ risk of Thromboembolism and stroke
TFT ♦ hyperthyroidism
Transthoracic ♦ structural HD (CMP, valvular dz, intracardiac shunt, pericardial
Types of AF: echocardiogram HDz),
♦ 1st detected episode - may not need tx if episode is brief/ known reversible cause (TTE) ♦ chamber sizes
♦ Acute AF – detected within 24-48h, has high chance of pharm/electrical cardioversion ♦ LV size and function.
♦ Paroxysmal AF – AF lasting less than 7 days Additional Invxs
♦ Persistent AF – >7 days 24h Holter ♦ Quantify freq & duration of symptomatic & asymp. AF episodes
♦ Permanent AF – previous attempts to restore sinus rhythm have failed/ AF lasted >1y. ♦ Look for sinus node dysf(x) or sick sinus syndrome
The probability of successful cardioversion is very low ♦ Assess adequacy of rhythm or rate control
♦ Assess time of onset of AF (eg night in vagally-mediated AF)
Clinical Presentations ♦ Identify PTs with frequent atrial ectopics & nonsustained atrial
♦ Palpitations tachycardia suitable for catheter ablation
♦ CP Transesophageal ♦ Gives better visualization of LA thrombus cf TTE)
♦ Dyspnoea echocardiogram ♦ Use before elective cardioversion in PTs w/o prior 3wks
♦ Fatigue (TEE) warfarin
♦ Light headedness Exercise stress test ♦ Assess PT with AF ppted by exertion, IHD or MI
♦ Syncope ♦ Routinely done for PTs ≥40YO or with significant coronary risk
♦ Cxs of AF – heart failure, haemodynamic impairments, stroke factors.
♦ Asymptomatic (25%) Electrophysiological ♦ For PTs w hx of syncope to exclude sick sinus syndrome and
study (EPS) Wolff-Parkinson-White syndrome
Evaluation of AF
♦ stable or unstable Management of AF:
♦ confirm diagnosis of AF with 12 lead ECG ♦ Aims: • Improve symptoms
♦ classify type of AF o Control ventricular rate • Reduce TE stroke risk
♦ determine underlying cause/factors contributing to AF (eg structural and ischaemic o Reestablish sinus rhythm • Prevent cardiac remodeling
HDz, estimating LVEF, valvular HDz, CMP, HPT) o Anticoagulate to prevent Thromboembolism and hence HFailure & CMP
♦ look for complications of AF
♦ determine risk of future complications, i.e. stroke, from AF Unstable:
o HTN/ old age/ IHD/ heart failure / previous stroke/ DM o immediate sync. Cardioversion
♦ Assess adequacy of control of ventricular rate during AF o f/u with anticoagulation therapy for 4 weeks
2. Stable:
a) Acute AF (<48h)
♦ Can be cardioverted (pharm/electrical) without prior long-term anticoagulation Rhythm Control:
♦ Give IV heparin before proceeding ♦ Spontaneous cardioversion occurs in 50-70% of PTs w/in 24 to 48 hrs, but unlikely to
♦ And switch to oral, maintain INR at 2-3 for 4 weeks whatever the outcome occur if AF persisted for > a week. Drug/electrical cardioversion will be necessary.
♦ Success rate of cardioversion decrease as duration of AF increase, therefore perform
b) Persistent/ Recurrent Paroxysmal AF early
If minimal symptoms, ♦ Problems: failure in maintenance of sinus rhythm in >50% of PTs, significant SE of
1) Rate control drugs used
o Beta-blocker
o Ca blockers e.g. diltiazem/ verapamil ♦ Pharmacological Cardioversion:
o Digoxin (esp if concurrent HF) Drug Comments SE
o Sotalol Class IC arrhythmics ♦ Contraindications ♦ conversion to atrial flutter
2) Assess for risk of thromboembolism and anticoagulate as necessary (propafenone 300- - IHD ♦ ventricular tachycardia
This is the recommended management for most patients, unless acute onset (<48h), or 600mg PO stat, - CCF ♦ enhanced AV nodal
symptomatic, or complicated flecainide150-200mg - Lt vent dysf(x) conduction
PO stat) - major conduction ♦ CCF
disturbances
c) Symptoms/ complications (e.g. syncope, heart failure, stroke)
Amiodarone ♦ Takes days to wks for onset ♦ Hepatotoxic
♦ Rate control initially followed by cardioversion, with anticoagulation
(600-800mg/day PO) ♦ Safe for PT with structural heart ♦ Thyroid dysfunction
♦ Then,
o anticoagulate for 3 weeks with warfarin (keep INR 2-3) before cardioversion
dz or heart failure ♦ GI upset
♦ Monitor LFT & TFT 6 mthly for SE ♦ Bradycardia
♦ Amiodarone
♦ Flecainide ♦ Torsades de pointes
♦ Propafenone ♦ polyneuropathy
o Alternatively, do TEE to look for LA thrombus. If none, give IV Heparin and Dofetilide & ibutilide ♦
perform DC cardioversion w/o prior anticoagulation. Quinidine ♦ Hypotension
♦ Post cardioversion, maintain INR at 2-3 for 4 weeks ♦ Torsades de pointes
♦ Maintenance of sinus rhythm (Flecainide, propafenone, sotalol, amiodarone) Sotalol ♦ NOT for cardioversion ♦ Torsades de pointes
♦ Only for maintaining sinus rhythm ♦ CCF
AF ♦ Exacerbation of COPD
♦ Electrical cardioversion:
Unstable Stable o PT must be fasted and sedated, with good IV access and airway Mx
o Check electrolyte and anticoagulation status
♦ Sync cardioversion Monophasic AF 200 joules, increments up to 360 joules
♦ 4 wks anticoagulation Atrial flutter 50 joules
Biphasic AF 100 joules initially
o Cxs: Thromboembolism, arrhythmia, myocardial injury, heart failure, skin burns.
st
1 episode / Acute AF (<48hrs) Persistant / recurrent
paroxysmal AF ♦ Other non-pharmacological rate control therapies
♦ Pharm / electrical cardioversion w/o prior anticoagulation o Permanent Pacing
♦ 4 wks anticoagulation o Catheter ablation – for PTs with paroxysmal AF due to atrial ectopics, PT with
♦ long-term anticoagulation not necessary SVT or atrial flutter
o Surgical ablation – “Maze” procedure: consider concomitant Sx ablation in PTs
going for open heart Sx for valvular, ischaemic or congenital heart dz.
Asymptomatic Symptomatic / complicated
♦ Maintenance of Sinus Rhythm
♦ Rate control ♦ Rate control & anticoagulation o Flecainide, propafenone and sotalol are first line drugs
♦ Long-term anticoagulation ♦ Cardioversion & maintain sinus rhythm o Amiodarone superior to previous drugs, but last choice of drug due to long term
♦ Long term anticoagulation extracardiac SE.
• Treat ppt factor if present
• Failure of drug therapy to achieve rate control or maintain sinus rhythm – consider
pacemakers, defibrillator or catheter ablation
3. o Choice of drug in heart dz:
Heart failure: use amiodarone ♦ Contraindications to anticoagulation
CAD: use sotalol ♦ Significant bleeding or fall risk ♦ PT unlikely to comply with diet &
HPT with LVH ≥1.4cm: use amiodarone ♦ Recent surgery / trauma monitoring regimen
♦ Thrombocytopenia ♦ Active peptic ulcer dz
Rate Control:
♦ Similar efficacy to rhythm control, but drugs used are safer and there is no problems ♦ Antithrombotic strategies
wrt maintenance of sinus rhythm Any high-risk factors present Long-term oral anticoagulation (target INR2.5;
♦ Pharmacological rate control: >60YO with one other range 2.0-3.0)
Drug Comments SE moderate risk factor
β-blockers ♦ First line Rx ♦ Bronchoconstriction. CI in <60YO + one moderate risk Either aspirin 100mg/day or warfarin depending on
(propranolol, atenolol, ♦ Caution in PTs with heart asthma factor PT preference, risk of blding and access to
sotalol) failure ♦ Heart failure 60-75YO with no risk factor anticoagulation monitoring
♦ Hypotension Male >75 with no risk factor
♦ Heart block Low risk or warfarin is CI Aspirin (100-300mg/day). Alternatives: ticlopidine,
♦ Bradycardia clopidogrel, dipyridamole
CCB (verapamil, ♦ IV CCB useful in ♦ Hypotension <60YO with no risk factors & Long term aspirin or no Rx
diltiazem) emergencies ♦ Heart block normal left atrial size
♦ Preferred over β-blockers ♦ Heart failure *always consider PT factors in determining target INR level (eg fall risk in elderly, recurrent
in PT with COPD TE events despite anticoagulation, prosthetic heart valves) & modify Rx accordingly
♦ Caution in PTs with heart
failure ♦ Monitoring: wkly INR initially, then 6-8wkly once INR stabilizes.
Digoxin ♦ Good for PT with heart ♦ Digitalis toxicity ♦ Adjustment of warfarin dose:
failure ♦ Heart block o after change in drugs that interact with warfarin (eg amiodarone)
♦ Caution in elderly and PT ♦ Bradycardia o surgery (stop warfarin for 5 days prior to surgery)
with renal dysf(x)
Amiodarone ♦ Good for PT with heart ♦ Thyroid dysfunction
failure ♦ Hepatotoxicity
♦ Not first line due to SEs – ♦ Torsades de pointes
require monitoring of LFT ♦ Warfarin & digoxin
and TFT interaction
*combination therapies are possible eg digoxin & β-blockers
♦ Non-pharmacological rate control:
Permanent pacing Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY,
AV nodal ablation & permanent pacing: o=UCSI University, School of Medicine, KT-
Campus, Terengganu, ou=Internal Medicine
Group, email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI year 4
students.
Anticoagulation: Date: 2009.02.24 10:15:03 +08'00'
♦ Prevent thromboembolic Cxs eg stroke & peripheral arterial thromboembolism
♦ Risk factors
High risk factors ♦ Prior stroke/ TIA/ systemic embolism
♦ Prosthetic heart valve
♦ Rheumatic mitral stenosis
♦ >75YO
Moderate risk factors ♦ 60-75YO ♦ LVEF ≤35%
♦ HPT ♦ DM
♦ CCF ♦ Thyrotoxicosis
♦ Coronary artery dz
Low risk factors ♦ <60YO