Meity Ardiana

Putri Rachmawati Dewi

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 Atrial

Fibrillation (AF) affects 12% of the

population, and this figure is likely to increase in the
next 50 years

The average age of patients between 75 and 85 years

AF is associated with a five-fold risk of stroke and a
three-fold incidence of congestive heart failure, and
higher mortality.
men

Prevalence,
percent

women

Age, years

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 Disorganised electrical and mechanical activity that

originates in the atria with an irregular response

Characteristics of AF :

Irregular R-R
interval

Fibrillation
waves
Heart Rate

A : > 300 bpm

V : slow to rapid

ESC 2010

Rhythm

P-Wave

Irregularly irregular

No distinct P waves
Fibrillatory

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Underlying Etiologies of Atrial Fibrillation

AHA 2014

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Classification of AF

ESC 2010

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1. Focal Mechanisms
The pulmonary veins (PVs) have a
stronger potential to initiate and
perpetuate atrial tachyarrhythmias

2. The multiple wavelet hypothesis

AF is perpetuated by continuous
conduction of several independent
wavelets propagating through the atrial
musculature
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Markides, 2003; Iwasaki 2011

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 All patients

History

Physical examination

ECG

Echocardiogram

Thyroid function

Selected patients

Holter monitor

Invasive procedure
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 Symptoms vary greatly among individuals and

include: anxiety, palpitations, dyspnea, dizziness,

chest pain, and fatigue/weakness, irregular heart
rate (Porth, 2005).

EHRA = European Heart Rhythm Association

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 Physical examination
Exophthalmos

,
valvular disease

Irregular pulse, pulsus deficit

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NICE Guideline 2014

Transthoracic Echocardiography
(TTE)
Baseline echocardiogram is
important for long-term
management
Rhythm-control strategy is being
considered
High risk or a suspicion of
underlying structural/functional
heart disease
Refinement of clinical risk
stratification for antithrombotic
therapy is needed

Transoesophageal
Echocardiography
(TOE)
When TTE demonstrates an
abnormality that warrants further
specific assessment
TTE is technically difficult and/or
of questionable quality and where
there is a need to exclude cardiac
abnormalities
TOE-guided cardioversion is
being considered

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GOALS

Hemodynamic
stabilization
Ventricular
rate control
Prevention of
embolic
complication

ESC 2010

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Rate Control
AHA/ACC/HRS Atrial Fibrillation Guideline 2014

ESC Guideline 2010

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Rate Control Agents

Drug Classes

Drug

Loading Dose

Maintenance Dose

Calcium Channel
Blockers (nondihydropyridine)initial DOC

Diltiazem

10 mg IV over 2
minutes
Can repeat up to 20
mg IV

30 mg PO q6 hrs
(can transition to
long acting)
Can use 10 mg IV
q6 hrs prn

Beta Blockers-initial
DOC

Metoprolol

5 mg IVP q5min x3
doses

25 mg PO BID, can
uptitrate to 100mg
PO BID

Digoxin

0.5 mg IV loading
dose0.25mg IV in
6 hrs0.25mg IV 6
hrs after

0.125 mg PO QD

Other

Other

Amiodarone

150 mg IV/10 min 100-200 mg PO QD

1mg/minx 6 hrs
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Rhythm control

ESC 2012
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RATE
CONTROL

VS

RHYTHM
CONTROL

THE TRIALS
AFFIRM STUDY (2002)
RACE (2002)
No differences
in quality of life with
PAF (2000)
rhythm control
compared
STAF
(2003) with rate control
HOT CAF (2004)
RACE II (2010)
Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.

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RATE
CONTROL
Persistent AF
Less symptomatic
Age 65 years old
Hypertension
No history of HF
Previous failure of
antiarrhytmic drug
Patient preference

Frankel, 2013

VS

RHYTHM
CONTROL
Paroxysmal AF or newly
detected AF
More symptomatic
Age < 65 years old
No hypertension
HF clearly exacerbated
by AF
No previous failure of
antiarrhytmic drug
Patient preference

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Antithrombotic management

CHA2DS2-VASc : congestive heart failure, hypertension, age 75 ,CARDIOVASCULAR EMERGENCIES COURSE

diabetes, stroke vascular disease, age 6574, and sex category
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(female)

ESC 2012 Atrial Fibrillation

Guidelines Update: Risk Assessment
Score CHA2DS2VASc
0

Risk
Low

Anticoagulation Considerations
Aspirin (81-325 mg) daily or none

Moderate

Aspirin daily or warfarin (INR to 2.0-3.0)

or dabigatran (Pradaxa) or rivaroxaban
(Xarelto) or apixaban (Eliquis), depending
on factors such as patient preference

2 or greater

Moderate or
High

Warfarin (INR 2.0-3.0) or

dabigatran (Pradaxa) or
rivaroxaban (Xarelto) or apixaban
(Eliquis)

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Importance of the HAS-BLED Score

Risk Score for Predicting Bleeding in
Anticoagulated Patients with Atrial Fibrillation

Hypertension (> 160 mm Hg systolic)

Abnormal renal or hepatic function
Stroke
Bleeding history or anemia
Labile INR (TTR < 60%)
Elderly (age > 75 years)
Drugs (antiplatelet, NSAID) or alcohol
High risk
Moderate risk
Low risk

(> 4%/year)
(2-4%/year)
(< 2%.year)

Pisters R, et al. Chest 2010; 138: 1093.

Lip GYH, et al. J Am Coll Cardiol 2010; 57: 173.

Weight (points)
1
1-2
1
1
1
1
1-2
>4
2-3
0-1

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Flowchart
anticoagulation
therapy

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AHA/ACC/HRS Atrial Fibrillation Guideline 2014

ESC Guideline 2010

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 Limitation of Warfarin
Slow onset of action
Genetic variation in metabolism
Multiple food and drug interactions
Narrow theurapeutic index

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New Oral Anticoagulants (NOACs)

Dabigatran

Rivaroxaban

RELY trial
ROCKET-AF trial
Direct thrombin
Direct factor Xa
inhibitor
inhibitor
110 mg b.i.d and
20 mg once a day
150 mg b.i.d doses

Apixaban
AVERROES trial
ARISTOTLE trial
Direct factor Xa
inhibitor
5 mg b.i.d. with a
dose adjustment
to 2.5 mg b.i.d

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Comparison Overview of New

Anticoagulants with Warfarin
Features

Warfarin

New Agents

Onset

Slow

Rapid

Dosing

Variable

Fixed

Yes

No

Many

Few

Yes

No

Half-life

Long

Short

Antidote

Yes

No

Food effect
Drug interactions
Monitoring

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Ablation
The technique of ablation :
To target individual ectopic within
the PV to circumferential
electrical isolation of the entire
PV musculature

Catheter ablation should be

reserved for patients with
AF which remains symptomatic
despite optimal medical therapy,
including rate and rhythm control.

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 Quality of life and exercise capacity are impaired in

patients with AF.

Patients with AF have a poorer quality of life

compared with healthy controls, the general

population, or patients with coronary heart disease
in sinus rhythm.

Hospitalisation can be limited to highly symptomatic

patients, those with structural heart disease, had an

embolic event or are at high risk of
thromboembolism, and patients with failure of rate
control in the emergency department
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 Atrial fibrillation (AF) is the most common sustained

cardiac arrhythmia, occurring in 12% of the general
population.

AF confers a 5-fold risk of stroke, and one in five of all

strokes is attributed to this arrhythmia.

AF is defined as a cardiac arrhythmia with the following

characteristics: The surface ECG shows absolutely

irregular RR intervals , there are no distinct P waves on
the surface ECG, the atrial cycle length (when visible), is
usually variable.

The management of AF including the rate control

strategy, rhythm control strategy, cardioversion and

antithrombotic therapy
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CARDIOVASCULAR EMERGENCIES COURSE

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Procedures: Ablation
A catheter is inserted into the femoral artery to
the area of heart muscle where there's an
accessory (extra) pathway.

The catheter is guided using fluoroscopy.

The physician is able to see the exact area on the
heart that is causing the accessory pathway

Radiofrequency energy is transmitted to the

pathway and destroys the selected heart muscle

cells in a very small area (about 1/5 of an inch).
(American Heart Association, 2010).
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ESC 2012

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