Atrial Fibrillation

DR. ZIRATH + DR. MEHTA

EPIDEMIOLOGY
Most common cardiac arrhythmia

33.5 million with AF in 2010

AGE

More prevalent in men and with increasing age

Overall prevalence of AF:

Patients 65 years or older:
Patients 70 years of older:

1%
70%
65%

SEX

Higher in men that women

RACE

More frequent in whites than blacks

DEMOGRAPHICS

Highest prevalence in North America, lowest in Japan and South Korea

CHARACTERISTICS
Multiple foci in the atria fire continuously in a chaotic pattern
Causes irregular, rapid ventricular rate
Instead of intermittently contracting, atria continuously quivers
Atria rate is over 400bpm but most pulses are blocked at AV node
Ventricular rate ranges between 75 and 175
Patients with AFib and underlying heart disease are at higher risk of

thromboembolism and other adverse effects

CLASSIFICATION
PAROXYMAL AF

Self terminating, usually within seven days of onset

PERSISTENT AF

Sustained > 7 days, termination with medication or cardioversion

LONG-STANDING AF

Typically > 1 year, and when cardioversion has failed

PERMANENT AF

Persistent AF where patient and physician no longer pursue rhythm control

VALVULAR

Rhuematic MV disease, prosthetic valve or valve repair

LONE AF

Age < 60 years, and w/o clinical or echo evidence of cardiac disease

RISK FACTORS
HTN (60 80%)
Cardiovascular disease, such as cardiomyopathy, valvular and CAD (25 to

30%)
HF (30%)
Diabetes (20%)
Age
Pericarditis, pericardial trauma
Pulmonary disease, such as PE
Hyper/Hypo-thyroidism
Systemic disease, such as sepsis, malignancy

DIAGNOSIS H&P
Not all patients with AF are symptomatic
Typical symptoms include:

Palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, mild dyspnea

Severe symptoms include:

Dyspnea at rest
Angina
Presyncope
Embolic event
Insidious RHF

DIAGNOSIS - ECG
ECG
Necessary to make the diagnosis
Errors are common with computerized interpretation of ECGs
Looking for:

LVH, Q-waves, Ventricular Pre-excitation, BBB

QT Interval: identify potential risk of antiarrhythmic therapy
SA dysfunctions

ECG FINDINGS
Irregularly irregular rhythm
Irregular RR intervals
No identifiable P waves
Rapid series of tiny, erractic spikes of ECG with a wavy baseline

DIAGNOSIS - ECG
ECG FINDINGS
Irregularly irregular rhythm
Irregular RR intervals
No identifiable P waves
Rapid series of tiny, erratic spikes of ECG with a wavy baseline

DIAGNOSIS - ECG

DIAGNOSIS - ECHO
ECHOCARDIOGRAM
Evaluate the size of RA, LA
Evaluate the function of RV, LV
Detect valvular heard disease, LVH, pericardial disease

Treatment

Goals of treatment

Control ventricular rate

Restore normal sinus rhythm
Assess need for anticoagulation

Treatment
Hemodynamically unstable patient
Immediate electrical cardioversion to sinus rhythm

Hemodynamically stable patient

Rate control
Conversion to sinus rhythm (after rate control is achieved)
Anticoagulation to prevent embolic cerebrovascular accident

 Rate control

Determine the pulse in a patient with A fib

If its too rapid, it must be treated
Target rate is 60 to 100 bpm
Beta blockers are preferred. Ca channel blockers are alternative
If LV systolic dysfunction is present, consider digoxin or amiodarone (for rhythm
control)

Rate Control Medications

CCB [Verapamil, Diltiazem]: Decreases BP, can worsen HF, preferred if
severe COPD, can increase digoxin levels
BB [Metoprolol, Propranolol]: Decrease blood pressure, watch for HF
and bronchospasm , preferred with CAD
Digoxin: consider in HF or low BP, poor exertional HR control
Amiodarone

Rhythm Control Medications

Amiodarone (class III): increase QT but TdP rare. Pulmonary, liver,

thyroid toxicity. Check PFTs, LFTs, TFTs

Dronedarone, Ibutilide, Dofetilide, Sotalol (other Class III): similar AE:
increase QT, risk of TDP, contraindications include permanent AF or sx
HF/ low EF; low K or high QT. Renally dosed.
Flecainide, Propafenone (Class 1C)
Procainamide (Class 1A): low BP, high QT, pretx with AVN blocker

Antiarrythmic Medications
If no disease or minimal HTN w/o LVH: Class IC, sotalol, dronedarone
HTN w/ LVH: Amiodarone
CAD: Sotalol, Dofetilide, Amiodarone, Dronedarone
HF: Amiodarone, Dofetilide

 Conversion to sinus rhythm

(after rate control is achieved)

Candidates: hemodynamically unstable, those with worsening symptoms, and first

ever case of Afib

Electrical cardioversion preferred over pharmacologic cardioversion. Attempt to

control ventricular rate before attempting DC cardioversion

Use pharmacologic cardioversion only if electrical cardioversion fails or is not

feasible: [parenteral ibutilide, procainamide, flecainide, sotalol, or amiodarone]

Cardioversion
Consider pharm or electrical cardioversion w/ 1 st AF episode or if sx
If AF >48h, 2-5% risk stroke w/ cardioversion (pharm or electric)
Likelihood of success linked to AF duration & atrial size; control precipitants
Consider pre-tx w/ antiarrythmic drugs (esp if 1 st cardioversion attempt

fails)
For pharmacologic cardioversion, class III and IC drugs have best proven
efficacy
If sinus rhythm returns (spont or w/ rx), atria may be mech. Stunned; also
high risk of recurrent AF over next 3 months
Anticoag postcardioversion > 4-12 wk

Nonpharmacologic therapy
Radiofrequency ablation: 80% success; reasonable alternative to

antiarrythmic drugs in sx persistent or paroxysmal AF w/o increased

LA or decreased EF
Surgical maze procedure (70-95%) success rate option if
undergoing cardiac surgery
LA appendage closure/resection: reasonable if another indication
for cardiac surgery percutaneous closure noninferior to warfarin,
decrease risk of ICH, but w/ procedural complications

 Anticoagulation to prevent embolism

If Afib present >48h (or unknown period), risk of embolization is significant (2 to

5%).
Anticoagulate patients for 3 weeks before and 4 weeks after cardioversion.
INR of 2 to 3 is the anticoagulation goal
To avoid waiting 3 weeks for anticoagulation, do a TEE to image the LA

If no thrombus start IV heparin and cardiovert within 24 hours. Patients still need 4
weeks of anticoagulation after cardioversion

Oral Anticoagulation
All valvular AF as stroke risk very high
Nonvalvular AF: stroke risk ~4.5% / year; anticoagulate 68% decrease in

stroke risk; use a risk score to guide Rx

CHADS2
CHA2DS2 VASc

Anticoagulate: score >/ 2

Score 1 consider anticoag or antiplt
Anticoag tx even if rhythm is controlled

Rx options: Factor Xa or direct thrombin inhibitor (non-valv only; no

monitoring required) or warfarin [INR 2-3; w/ UFH bridge if high risk of

stroke]; if Pt refuses anticoag, consider ASA + clopi or, even less effective, ASA
alone

THROMBOEMBOLIC RISK
Most important adverse outcome of AF
Maintaining sinus rhythm DOES NOT reduce the frequency of

thromboembolization
CHADS2 Score for Stroke Risk Assessment

Congestive Heart Failure 1 point

Hypertension
1 point
Age = 75 years
1 point
Diabetes
1 point
Stroke
2 points

TREATMENT RECOMMEDATIONS BASED on CHADS2

Chronic A Fib
1) Rate control with a B-blocker or CCB
2) Anticoagulate

patients with lone A Fib under age 60 do not require anticoagulation (b/c they are at
low risk for embolization)- ASA may be appropriate.
Treat all other patients with chronic anticoagulation (warfarin)

Thank You