Atrial Fibrillation Dr Nidhi Bhargava 8/10/13. Most Common sustained clinical arrhythmia Most Common sustained clinical arrhythmia Incidence rises with.

Atrial FibrillationAtrial Fibrillation

Dr Nidhi Dr Nidhi BhargavaBhargava

8/10/138/10/13

Most Common sustained clinical Most Common sustained clinical arrhythmiaarrhythmia

Incidence rises with age- >5% Incidence rises with age- >5% over the age 65-75over the age 65-75

Risk factors for AFRisk factors for AF

Hypertension- accounts for 14% of AF in Hypertension- accounts for 14% of AF in populationpopulation

Heart failureHeart failure Male sexMale sex DiabetesDiabetes ValvularValvular MIMI LVHLVH LVSDLVSD Left atrial dilatationLeft atrial dilatation Lone AF- with no structural or functional heart Lone AF- with no structural or functional heart

disease- 15%disease- 15%

Types of AFTypes of AF

Paroxysmal or recurrent (intermittent Paroxysmal or recurrent (intermittent and self terminating)and self terminating)

35-66% of all AF cases peak prevalence 50-69yrs35-66% of all AF cases peak prevalence 50-69yrs At least a quarter may go progress to permanent At least a quarter may go progress to permanent

AFAF

Persistent (does not terminate Persistent (does not terminate spontaneously but may be effectively spontaneously but may be effectively cardioverted)cardioverted)

Permanent ( no longer reversible or Permanent ( no longer reversible or reverses for brief interval only)reverses for brief interval only)

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Effects of AFEffects of AF

Haemodynamic effectsHaemodynamic effects– Loss of atrial contraction and AV Loss of atrial contraction and AV

synchronysynchrony– Rapid ventricular rateRapid ventricular rate– Irregular ventricular rateIrregular ventricular rate

Effects of AFEffects of AF

SymptomsSymptoms– PalpitationsPalpitations– BreathlessnessBreathlessness– Chest painChest pain

Effects of AFEffects of AF

ThromboembolismThromboembolism– Valvular AF -more so in pts.. with Valvular AF -more so in pts.. with

MS and AF (6% per year)MS and AF (6% per year)– Non Valvular AF- 4-5 times increased Non Valvular AF- 4-5 times increased

risk of stroke overallrisk of stroke overall– Further increased risk if Further increased risk if

– Previous stroke or TIA (20Previous stroke or TIA (20x increased risk)x increased risk)– Age >65, Hypertension and diabetesAge >65, Hypertension and diabetes– CAD, LV dysfunction and Left atrial dilatationCAD, LV dysfunction and Left atrial dilatation– <65 yrs. risk 1% per annum<65 yrs. risk 1% per annum

Effects of AFEffects of AF

Mortality- doubled in both sexesMortality- doubled in both sexes Increased risk of stroke 4-5 fold Increased risk of stroke 4-5 fold

increase- further increase with increase- further increase with age from 1.5% in sixth decade to age from 1.5% in sixth decade to 23.5% in the ninth decade23.5% in the ninth decade

TreatmentTreatment

Restoration of sinus rhythmRestoration of sinus rhythm Pharmacological cardioversionPharmacological cardioversion Electrical cardioversionElectrical cardioversion

– ExternalExternal– InternalInternal

TreatmentTreatment

Maintenance of sinus rhythmMaintenance of sinus rhythm DrugsDrugs DDD pacingDDD pacing Ablation of AF triggersAblation of AF triggers Surgery for AFSurgery for AF

Ventricular Rate ControlVentricular Rate Control

AnticoagulationAnticoagulation

Treatment Treatment

Cardioversion (pharmacological and Cardioversion (pharmacological and electrical)electrical)– Electrical cardioversionElectrical cardioversion

External and InternalExternal and Internal External- under GA, success rate 65-90%, 200-360JExternal- under GA, success rate 65-90%, 200-360J Internal- under sedation- percutaneous electrode- Internal- under sedation- percutaneous electrode-

success rate 90%success rate 90%– Pharmacological cardioversionPharmacological cardioversion

– Most effective if administered within 24 hrs. of onsetMost effective if administered within 24 hrs. of onset– Flecainide most effective- 72-95%Flecainide most effective- 72-95%– Others include amiodarone , sotalol, propafenoneOthers include amiodarone , sotalol, propafenone– Less effective in chronic AF- Amiodarone most effective Less effective in chronic AF- Amiodarone most effective

At least 4 weeks of full anticoagulation At least 4 weeks of full anticoagulation Anticoagulation to e maintained for 4 weeks after Anticoagulation to e maintained for 4 weeks after

successful cardioversionsuccessful cardioversion

TreatmentTreatment

Maintenance of Sinus rhythmMaintenance of Sinus rhythm– DrugsDrugs

Flecainde and Propafenone (Class 1c)Flecainde and Propafenone (Class 1c) Sotalol better then propafenoneSotalol better then propafenone Amiodarone – most effective but multiple Amiodarone – most effective but multiple

side effectsside effects Beta blockers- no date availableBeta blockers- no date available Digoxin- no effectDigoxin- no effect

– PacingPacing DDD pacing- reduce AF paroxysmsDDD pacing- reduce AF paroxysms Continuous atrial pacing-dual site or Continuous atrial pacing-dual site or

biatrialbiatrial

TreatmentTreatment

Focal AblationFocal Ablation Targets AF initiating foci located in Targets AF initiating foci located in

proximal pulmonary veinsproximal pulmonary veins Radiofrequency energy deliveredRadiofrequency energy delivered Used for pts. with paroxysmal AFUsed for pts. with paroxysmal AF Pts. with chronic AF but can be Pts. with chronic AF but can be

successfully cardioverted at least for successfully cardioverted at least for few seconds few seconds

Under LAUnder LA Success rate 70% in PAF and 50% in Success rate 70% in PAF and 50% in

chronic AFchronic AF

TreatmentTreatment

Surgery for AF-Maze operationSurgery for AF-Maze operation

Ventricular rate controlVentricular rate control AV node ablationAV node ablation DrugsDrugs

Digoxin- not negative inotropic but less Digoxin- not negative inotropic but less effectiveeffective

Diltiazem, verapamil and beta blockers- Diltiazem, verapamil and beta blockers- more effective but negatively inotropicmore effective but negatively inotropic

Case historiesCase histories

A 67 years old female with no risk factors presents with A 67 years old female with no risk factors presents with palpitationspalpitations

A 77 years old male with no risk factors is found to be in AF on A 77 years old male with no risk factors is found to be in AF on routine examinationroutine examination

A 98 years old male with AF on warfarin presents with A 98 years old male with AF on warfarin presents with haematuria and subsequently diagnosed with Ca bladderhaematuria and subsequently diagnosed with Ca bladder

A 79 year old female with AF rate 120-140/min, on warfarin A 79 year old female with AF rate 120-140/min, on warfarin and digoxin, asthmatic and has severe reaction to verapamil-and digoxin, asthmatic and has severe reaction to verapamil-treatment optionstreatment options

A 64 years old diabetic is in AF on routine examinationA 64 years old diabetic is in AF on routine examination