Atrial Fibrillation

•Rate or rhythm control?

•Who should be anticoagulated?

•Other treatment strategies

Classification:

Aetiology

LONE AF

ALCOHOLRHEUMATIC

HYPERTENSIONHYPER THYROIDISM

ISCHAEMICETC

VS

Classification:

FIRST EPISODE

PERSISTENTPAROXYSMAL

PERMANENT

RECURRENT

OR

TimingAetiology

LONE AF

ALCOHOLRHEUMATIC

HYPERTENSIONHYPER THYROIDISM

ISCHAEMICETC

VS

Circulation 2001;104:2118 –2150

Prevalence of AF:

JAMA. 2001;285:2370-2375

Mechanism of AF:

Mechanism of AF:

Mechanism of AF:

Burden of AF:

AF5% > 65

Fatigue

Palpitations

Syncope/Presyncope

Burden of AF:

AF5% > 65

Heart Failure

Fatigue

Stroke

Palpitations

Syncope/Presyncope

DyspnoeaOedema

Prognosis of AF:

Circulation 1998;98:946-952

Principles of management:

1. RESTORATION & MAINTENACE OF SINUS RHYTHM‘Rhythm control’

2. CONTROL OF VENTRICULAR RATE‘Rate control’

3. REDUCE THROMBOEMBOLIC RISK

Restoration of SR:

RESTORATION OF

SINUS RHYTHM

ELECTRICAL

1) EXT DC SHOCK

2) INTERNAL SHOCK

PHARMACOLOGICAL

1) FLECAINIDE:

2) PROPAFENONE

3) AMIODARONE

4) DOFETILIDE

NB 60% REVERT SPONTANEOUSLY IN <24 HOURS

Restoration of SR:

RESTORATION OF

SINUS RHYTHM

ELECTRICAL

1) EXT DC SHOCK

2) INTERNAL SHOCK

PHARMACOLOGICAL

1) FLECAINIDE:

2) PROPAFENONE

3) AMIODARONE

4) DOFETILIDE

NB 60% REVERT SPONTANEOUSLY IN <24 HOURS

ANTICOAGULATION?

HOW LONGIN AF?

<48 HOURS

NO HEPARIN

3 WEEKS WARFARINPOST SHOCK

>48 HOURS

3 WEEKS WARFARINPRE & POST SHOCK

or

TOE GUIDED SHOCK+

3 WEEKS WARFARINPOST SHOCK

Maintenance of SR (=prevention of AF recurrences):

1) DRUG TREATMENT:

Maintenance of SR (=prevention of AF recurrences):

2) OTHER TREATMENTS:

•Pacing

•Atrial Defibrillators

•Cardiac Surgery

•Catheter radiofrequency ablation

Rate control:

VENTRICULARRATE

CONTROL

PHARMACOLOGICAL

1) DIGOXIN

2) BLOCKER

3) CA CHANNEL BLOCKER

4) AMIODARONE

ABLATION

RADIOFREQUENCYABLATION OF ATRIOVENTRICULAR NODE

+PACEMAKER

Rate vs rhythm control:

Rate (Remain in AF): Rhythm (Restore SR):

advantagesGood symptom control Good symptom controlSimple low risk treatment Normal physiology/cardiac function

Better prognosis ??

disadvantagesAbnormal cardiac function Complex higher risk treatmentStroke risk ?? Antiarrhythmic drugs - proarrhythmicWorse prognosis??

Rate vs rhythm control - PIAF:

440

460

480

500

520

540

560

580

Baseline 3 12 24 52

Weeks

Wal

kin

g d

ista

nce

(m

)

Rhythm

Rate

PIAF study Lancet 2000;356;1789-94

Rate vs rhythm control – AFFIRM:

AFFIRM study - NASPE 2002

n = 4000 age = 70

Rate:

•Digoxin

• Blocker

•Ca channel blocker

Rhythm:

•Amiodarone

•Propafenone

•Sotalol

•+/- DC Cardioversion

Risk of Stroke?

Optimal INR?

•1 in 6 strokes have AF

•6 x stroke rate if have AF

•TYPE OF AF IS NOT A RISK DETERMINANT

Who should be anticoagulated?