EDUCATIONAL OBJECTI VE: Readers will manage newly diagnosed atrial brillation appropriately Managing newly diagnosed atrial brillation: Rate, rhythm, and risk ■ ABSTRACT The treatment oatrial fbrillation ocuses on controlling the heart rate, preventing thromboembolic events, and, depending on the symptoms, restoring and maintaining sinus rhythm. In most cases, the rate or rhythm can be quickly controlled, and a long-term plan can be started that will minimize the impact othis disorder on the lie othe patient. ■ KEY POINTS When atrial fbrillation is newly diagnosed, reversible causes and commonly associated processes should be sought. Agents to control the heart rate, eg, beta-blockers or nondihydropyridine calcium channel blockers , are oten started and titrated intravenously and then changed to oral dosing. The beneft orhythm control has not been frmly estab- lished. Although we try cardioversion at least once when atrial fbrillation is frst diagnosed, rhythm control is generally reserved or patients whose symptoms persist despite rate control, or or patients in whom the heart rate cannot be controlled. The need or short-term or long-term anticoagulation must be estimated. T hree general concerns ditttmmt tibiti: •Ctitt t•Ctiymptm•Pvtitmbmbivt, i- uditk. Wiptit witwy di- d tibiti, tmt- ud bkpt imid, but vd- ditiiumut bddd: •Rvibutibitimut bud ut •Ttutimt ttibi- tid tquy tpidud btid, ipib•A utimtitptit’ymp- tm budud bmd. Atibitiimmd uimpt itmtmbidity, dt, d titd witit. It tmt2.2 miiAmi. 1 Appximty 1 i10 ppvt80 tibi- ti, d tvt40, ti- timik dvpiit iiu. 2 Fm- im dtut tt tik dtippximty twiiptitwittibitimpd witimi- t witut. 3–5 ■ IMPORTANT QUESTIONS DURING THE INITIAL WORKUP Does the patient have a reversible cause oatrial fbrillation? Atibitiitut tbdutti- tt iititit d tmydiub- REVIEW doi:10.3949/ccjm.78a.09165 CREDIT CME THOMAS CALLAHAN, MD Department oCardiovascular Medicine, Cleveland Clinic BRIAN BARANOWSKI, MD Department oCardiovascular Medicine, Cleveland Clinic 258 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 4 APRIL 2011
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EDUCATIONAL OBJECTIVE: Readers will manage newly diagnosed atrial brillation appropriately
Managing newly diagnosedatrial brillation:Rate, rhythm, and risk
■ ABSTRACT
The treatment o atrial fbrillation ocuses on controllingthe heart rate, preventing thromboembolic events, and,depending on the symptoms, restoring and maintainingsinus rhythm. In most cases, the rate or rhythm can bequickly controlled, and a long-term plan can be startedthat will minimize the impact o this disorder on the lieo the patient.
■ KEY POINTS
When atrial fbrillation is newly diagnosed, reversiblecauses and commonly associated processes should besought.
Agents to control the heart rate, eg, beta-blockers ornondihydropyridine calcium channel blockers, are otenstarted and titrated intravenously and then changed tooral dosing.
The beneft o rhythm control has not been frmly estab-
lished. Although we try cardioversion at least once whenatrial fbrillation is frst diagnosed, rhythm control isgenerally reserved or patients whose symptoms persistdespite rate control, or or patients in whom the heartrate cannot be controlled.
The need or short-term or long-term anticoagulationmust be estimated.
Three general concerns ditt tmmt ti biti:
• Cti t t t• Cti ymptm• Pvti tmbmbi vt, i-
udi tk.W i ptit wit wy di-
d ti biti, t m t - ud b kpt i mid, but v d-diti iu mut b ddd:• Rvib u ti biti mut
b ud ut
• T tu tim t t ti bi-ti d t quy t pidud b tid, i pib
• A u timti t ptit’ ymp-tm bud ud b md.
Ati biti i mm d uimpt i tm t mbidity, dt, dt itd wit it. It t m t2.2 mii Ami.1 Appximty 1 i10 pp v t 80 ti bi-ti, d t v t 40, t i-
tim ik dvpi it i i u.
2
Fm-im dt ut tt t ik dt ippximty twi i ptit witti biti mpd wit imi -t witut.3–5
■ IMPORTANT QUESTIONS DURINGTHE INITIAL WORKUP
Does the patient have a reversible causeo atrial fbrillation?Ati biti i tut t b du t ti-
tt iitit it d t mydi ub-
REVIEW
doi:10.3949/ccjm.78a.09165
CREDITCME
THOMAS CALLAHAN, MDDepartment o CardiovascularMedicine, Cleveland Clinic
BRIAN BARANOWSKI, MDDepartment o CardiovascularMedicine, Cleveland Clinic
258 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 4 APRIL 2011
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CALLAHAN AND BARANOWSKI
tt tt uppt it. Wi it my dvpi t b t t di, it it itd wit ypti, dibt,bity, tutu t di (iudi
it t di), btutiv pp, dvd , d bu.
T, ti biti bdid, t ity, xmiti, d di-ti wkup ud b ditd twd k-i pttiy vib u d quty itd mbiditi. Cmmvib u iud: Hyperthyroidism. T bty vu-ti ud iud tytpi (tyid-timuti m, TSH) v. Alcohol use, piy bi diki.
Obstructive sleep apnea, i uptd t bi t ity t bdy bitu.
Structural heart disease u vvut di it t dt my pdip t ti biti. T-, it uy t t t d bti tti dim i tdy b d i yu upt i vvu di yti uti it mt t tudy.
How long has the patient beenin atrial fbrillation?T duti t ti biti t -t t ttmt tty. T, wt dii b md, it i imptt tty t timt w t ptit bi ti biti.
Ot, w mut tt timt, t ptit’ ti my b vu. Hw-v, i m , t ymptm p-ud tdipi tmtidt vib, wi t tim t
t b y dd.I dditi, it i pu t kw i t p-tit d pi pid tt w vbut t mdi ttti. T ti d,iit t ptit’ ptum ymptm du im t tik bk mt y d ty t t tim w imi- ymptm mit v ud.
How do the symptoms aectthe patient’s quality o lie?T iii mut timt t xtt t
wi t ymptm t t ptit’ qu-
ity i. Ti i bt d w t tt i ud t. I t ptit ti iit ymptm dpit dqut tt, t ytm t tty ud
pbby b puud.
■ MANAGING NEWLY DIAGNOSEDATRIAL FIBRILLATION
Control the heart rate with a beta-blocker,a calcium channel blocker, or digoxinMy ptit pt dui ti t pi-d ti biti wit pid v-tiu t, piy i ty t dytki du t w duti tu ttivtiu d. I t ymptm
ptiuy pud, ud ty t tt t t ud t quiky.
O t tk tim t b bbd d t wy y t titt. Itvubt-bk u mtp (Lp)d bt (Nmdy, Tdt) i-tvu ditizm (Cdizm) w tt t quiky d b tittd. Ot t t i td, t m b ttd, t w wi m t itv-u t. I ut mmt, w k t t t but 100 t 110 btp miut.
I t ptit’ bd pu i mi,di wit itvu dixi my b -idd. T d i 0.5 m itvuy,t 0.25 m itvuy i t t 6 ud t 0.25 m itvuy i t6 u. I ptit wit iuiyt d ud b , dixi ud bvidd tt. Ot, t bd puwi impv t t t i dd,wi t t t b iititd. Hwv,
i t ptit i ky yptiv wit tpi, t bt, dimiid v- iu, t my tidivi i iditd v i tiu-ti t yt b ttd (m buttiuti bw).
O m t m t t wk- t t t i t utptittti. O bt-bk d diydpyi-di ium bk (i, ditizm vpmi [C, V]) t t-it, bu w dixi i ud , it
i tivy p t ti t t t,
We try
to restore
sinus rhythm
at least once
when atrial
fbrillation
is frst ound
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ATRIAL FIBRILLATION
piy w t ptit i t t t.T i btw t t ud
b dittd by wt t ptit m-biditi u y ty di, t
iu, tiv iwy di. Ndiy-dpyidi ium bk -tivy tiditd i ptit wit tiu, wi bt-bk xbttiv iwy di.6
It i imptt t dumt tt tt t i dquty td utid tpit utptit ii, w t p-tit i typiy itti upi. Ti bd wit 6-miut wk, xi tt, Ht mit t-ti tv b tittd.7
When to try to restore sinus rhythmW ti biti i t did, it myt b pib t dtmi i it i pxym(i, -tmiti) pitt. I t pidd t quiky d it w, idtimy b iv t ti iu ytm.
Atu xpt dbt t mit t t pp v ytm t p-p mi ti biti i t tm, my, iudi uv, m-md tyi t t iu ytm t t w ti biti i t divd.It i t wy i ti biti ituy ymptmti. Symptm u tiu dd xi t b ubt.Additiy, t ymptm my b ttib-utd t t t u dditii,bity, dvi . Tu, i my -, y ti m iu ytm tim w t ptit d iii t uy t ymptm ttibutb t ti -biti.
T, i ptit wit wy di-d ti biti, ttmpt t tiu ytm i t wtd. Expti i t ptit w v pptymptm d w vy d dmdt i t tt divi. Direct-current cardioversion i typiyt ttmt i w ttmptit t iu ytm. T pdu b d witut tiuti witi 48u t t ti biti, i ttim t i .7 Hwv, iii
mut b u i di t t ti
biti ti pup.Symptm u tiu t
bt b vu i tm t xt tim t d t t b id up
t pup didi wt divi b d witut tiuti. Wi dubt, it i bt t t id tyd um tt t ti biti bi m t 48 u.
I t tim t i u i m t48 u v pd, t tw tt-i pdi t ti divi.
O i t order transesophageal echocar-diography d bi tiuti tpyt t m tim. I t i tmbu it t tium, t divi b
d.8 Tputi tiuti wit p-i, w-mu-wit pi, w-i (Cumdi) ud b ivd witi 24t 48 u tp di-py d divi t miimiz t ik tmbmbi vt, wi uv t iu ytm b td.
At u itituti, w typiy tiv tiv tputi tiuti wit i-t pi w-mu-wit pib divi i ti i tvid ituti i wi ptit my u-d divi but t i t ivtputi tiuti m tim dut u t.
T t pp i t start wararin d miti itti mizdti (INR) 2 t 3 3 wk, t witim divi b pmd ywitut tp dipy.8
Rd wi tty i ud, ti-uti ud b tiud t t 4wk t divi,8 ti dyutid t ik tk my pit dy twk t m iu ytm i td.9
Role o antiarrhythmic drugsAtiytmi du b ud mi- divi , m t, t p mi-ti iu ytm t dit-ut di-vi.
Bu mt t du v t t m ti m iu ytm,w d t w t m u w tt-i tm w pmi dit-ut
divi. Ptit ud t b ttd
I atrial
fbrillation
has lasted
> 48 hours
or i you are
not sure,
anticoagulate
beore
cardioversion
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CALLAHAN AND BARANOWSKI
tiytmi mditi uti tyv d dqut tiuti t t3 wk dqut tiuti d tp dim mi
tt t i tmbu i t t tium.Atiytmi du ud b ttd
i t ptit wit wy did tibiti i wm ytm t tt-y wi b puud. F ptit w i-ty ut i pid, pid ttpviuy -tmitd, tiytmimy t b y. F t wit qutpid w ity ut iti biti pid, ti-ytmi wi iky b quid t pvid b ivi dm m
ti biti.T i tiytmi du ud
b tid t t pi ptit.Propaenone (Rytm) d fecainide
(Tmb) t-i du7 but -tiditd i ptit wit y tydi d iit tutu t di-.10
Sotalol (Btp) d doetilide (Tik-y) b ud i ptit wit yty di. Hwv, t i tidi-td i ptit wit tiv t iu,d dtiid i it du it-ti. Bt mut b ud wit xtm u-ti i ptit wit iuiy, dpit dmii i quid iititi upwd titti t d. Amiodarone (Cd) i tiv, di t t tm it i typiy vy w t-td. Hwv, it -i, d itptti -tm txiity t mkit p i -tm ttmt. Ttxiity mid i wit t u-mutiv d. T, ti du ud bvidd -tm tpy ti bi-ti i yu ptit.
The ‘pill-in-the-pocket’ strategyT “pi-i-t-pkt” tty, i wi p-tit itutd t tk ti mditiy w ty v but ti bi-ti, i b pti ptit witymptmti u pxym tibiti. Ti tty i miy vd ptit w v tivy iqut u-
. T w v qut u
uuy m tivy ttd wit diydi tiytmi. Fiid dpp t t i tipp bu ti ty p d -
y i mi divi.Wi ti tty my b ttd
utptit bi i ptit wit , px-ym ti biti, t wit tutut di duti bmitiud b bvd i t pit dui ii-titi tpy t bv xiv PRpti dvpmt du wim ytmi.11–13
Additiy, t t d tty pid t tivtiu d,tby ii t vtiu t. I t
ti futt, ptit my b vtdm vib 2:1 p t 1:1 du-ti. Tu, ud id ui bt-bk wit ti tty.
Si t ti pp i t -vt t ptit t iu ytm witi wu t t ti biti, it myb impmtd witut t u wi.Ptit itutd tt i ty d tvt t m iu ytm witi wu, ty ud tiy t pyii ty ud ti divi witit 48-u widw m t t tibiti.
Dronedarone, a new antiarrhythmic drugDd (Mutq) i w vib d b w t b tiv i ttiti biti.14 It -i d mim ti imi t tt mi-d. Hwv, it my b ii t mi-d i tm y.15 It i mtbizdby CYP3A4. N d djutmt i dd ptit wit iuiy.
Bu dd k t idi mi-ty ud i mid, it ud t yt m txiity p. N pumy tyid txiity w ptd i y ti.16
Nvt, dd vimptt imitti. It i bk bxwi tti it i tiditd i p-tit wit v ty dmptdt iu, t mtity t w twi i w ti du w ud i u ptiti iiti tudi.17 Additiy, t v
b pt pttxiity quii iv
Continue
anticoagulation
or at least
4 weeks ater
cardioversion
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ATRIAL FIBRILLATION
tptti i m umb ptit.T xtt ti pbm d tti vidi it t yt dd t witi ti pp. A wit y w mditi, p-
tit w ttd dd udb bvd y y id t, dt ud b ptd t it i t dv-pmt t du’ ty p.
Pulmonary vein isolationI pdu tt pttiy u tibiti, tt itd it tt tium d i tiu tdud t ti t pumy vi uidiquy y, tiy ititm m t t t t tium.
Sm dbt xit t wt ti p-du my b b t-i tpy m ptit wit ti biti.18,19 Itmy b idd y ttmt tt-y i m ubt ptit, piyyu ptit wit ymptmti, utti biti, piy i ty vt -tm tiytmi tpy.
Bu ptit my ti b m p tti ytmi v wk t mtt t pdu, ty mut b b t t-t tiuti wit wi t tv mt.
Rate control vs rhythm controlT i btw t t tty ytm t tty i t tm it wy titwd. Wi ti bi-ti i y itd wit i m-bidity d mtity t, t w dtt dt wi tt ti d miti-i iu ytm i ptit wit ti bi-ti du t iid mbid mpi-
ti t ikid dt.Tu, ut uidi mmd t t tty i ptit w v ymptm, d ytm t tty i t t t b ivd i ymp-tm pit dpit dqut t tt t.7 T iumt d p- t idividu ptit ud ywit i ti dii.
Ti ud wy tt my d mit t tiv bt ytm -t wit bti tiytmi d t
t.
■ PREVENTING THROMBOEMBOLIC EVENTS
WararinI t t tm, wi tpy my b
dittd by p t t iu ytm. P-tit d wi t t 4 wk tdivi u it i pmd witi 48u t t ti biti. The CHADS2 score (1 pit ctiv t iu, hypti, a 75 d, d dibt mitu; 2 pit pi- stk tit imi ttk) i u-u w didi wt t iv -tmtiuti.
F ptit wit 0, t ik tk i w t t ik mj bd-
i mpiti wi tputi w-i.20,21 F t ptit, pii 81 t 325 mdiy i mmdd tk ppyxi.
F t wit 2 t, tik tk witut wi i t tt ik mj bdi mpiti witwi. T ptit ud iv w-i wit INR 2.0 t 3.0.7
Ptit wit CHADS2 1 pt dimm, ti ik tk witut w-i i but t m ti ik mjbdi mpiti wit wi. Ty b md wit it wi pii, -di t t pyii’ judmt.7 I t, t u bbi pitt mit i t ik bdi, p-ivd quy ti biti pid,d v ptit ppti but w-i t ud w didi btw pi-i d wi.
Ptit wit CHADS2 2 t wit i pid ti bi-ti d iky vib u my p dimm w didi wt t ttwi. T ptit v dmttdty t t v t ubtt t mititi biti. Ti ituti i pyii judmt. B i mid tt ymp-tmti u mm i ptitwit ti biti.22,23 A i CHADS2 dt t ik tk d myifu ti dii. It i uuy bit it t ptit i ti dii-mkip, ptit t v vy tpii but t t ik tk
wi tpy it.
With a CHADS2
score o 1,
the risk
o stroke
o wararin
equals the risk
o bleeding
on wararin
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CALLAHAN AND BARANOWSKI
Aspirin,
with or without
clopidogrel,
may be an
alternative
i wararin is
contraindicated
At tty i t tt tiutiwit wi d ivy mit -u. I t ptit u ti biti t 6 t 12 mt d t
vib u i vd, t -viit t d wi.
Role o aspirin and clopidogrelApii, i juti wit pi-d (Pvix), my pvid ttiv tk ppyxi i ptit i wm w-i i tiditd. Wi ii t w-i, t mbiti pii d pid- b w t d t iid mj tmbmbi vt, piytk.24 Hwv, t ik mj bdi
mpiti w iity id.Ti mbiti my b b
tty i t ptit wit CHADS2 2 t i wm wi tb ud u p vit t mditi, id t, bd-i mpiti i ptit w INR ixdiy diut t kp witi t t-puti .
Dabigatran, a new anticoagulantT wt pti tiuti i p-tit wit ti biti i dit tm-bi iibit, dbit (Pdx).
I t Rdmizd Evuti L-Tm Atiuti Tpy (RE-LY)ti,25 dbit w tudid d-t-dwit wi. T d dbit tudidw 110 m d 150 m twi dy. At 150m twi dy, ptit dbit d w t tk t wit wi (1.11%v 1.69%, P < .001), w w t t vu ytm bdi (0.10% v0.38% wit wi, P < .001). T t mj bdi w mpb i t p-tit ivi wi dbit 150m twi dy, but t t tittibdi w i i t dbit up(1.51% v 1.02% wit wi, P < .001).25
Dbit w ty ppvd by tUS Fd d Du Admiitti u iptit wit ti biti. D 150m d 75 m vib.
Dbit i y xtd, d t150 m twi--dy di i itdd p-
tit wit tii t t
30 mL/mi. T 75-m twi--dy di iitdd ptit wit tii - 15 t 30 mL/mi. Hwv, it udb td tt uty t dt t
uppt t 75-m twi--dy di.Dbit d v v dvt
v wi. Ptit d t d t vidd tii vitmi K, d uti -i miti d t pp t b dd.A wit y w mditi, ptit w ttd dbit ud b bvdy y id t, d t udb ptd t it i t dvpmt tdu’ ty p.
■ SPECIAL CIRCUMSTANCES
Ater cardiac or noncardiac surgeryAti biti i mm t p tuy, ui i ppximty 25% t50% ptit.26–28
W ti pp, t t twttmpt md t t iu ytm.Epiy i t y ptptiv pid,tiuti wit pi wi myb tiditd, u ttti mutb pid t t ptit’ t ytm ttti biti b izd quikyd divi pmd witi 48-uwidw t. Bt-bk, ditizm, dvpmi typiy ud t t.
W ti biti u i ptitw v ud p t uy, -tiytmi ttd y t p p-vt ut u. At u itituti,w uuy u mid, it i iy -tiv d w ttd i t t tm.W ttd mid ptp-tiv ti biti, ptit imd
tt t du wi b tppd t but 2 t3 mt. F ptit w tiu t vbut ti biti, t d ti-ytmi mditi b d, d,i dd, t ptim tiytmi mdi-ti -tm tpy t ptit b .
Atrial fbrillation in severe, acute illnessAti biti i mm i t tti xtm ytmi t u k dpi d w t ptit i bi upptd
wit itpi t. I ti tti, ptit
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ATRIAL FIBRILLATION
my b i i-tmi tt, dbt t t t d t t ytm myb vy diut t t.
Bt-bk d diydpyidi
ium bk ud t bud w ptit mditi tuppt bd pu, d i ti tti,w t ptit’ mdymi ttu p-mit t u t t, ti t myb miim.
Amid pp dixi my w
t t t mwt witut t mut t bd pu. Hwv, witmid, my v t pt ik mi divi.
Eti divi wit wit-ut t it tiytmi dumy t t t t by ti iuytm. Hwv, ti biti t -u, d i it u quiky my v tpt vtd t t uti t udy-i p i ddd. ■
■ REFERENCES1. Go AS, Hylek EM, Phillips KA, et al. Prevalence o diagnosed atrial
brillation in adults: national implications or rhythm management
and stroke prevention: the Anticoagulation and Risk Factors in