Atrial Fibrillation Current Management Strategies.
-
Upload
barrie-gordon -
Category
Documents
-
view
232 -
download
1
Transcript of Atrial Fibrillation Current Management Strategies.
![Page 1: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/1.jpg)
Atrial Fibrillation
Current Management Strategies
![Page 2: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/2.jpg)
Overview
• 25% will develop AF during lifetime• 4% above 60• 8% above 80• Total sufferers to double by 2050• Doubles annual risk of death
(Framingham)• 5% annual risk of stroke
![Page 3: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/3.jpg)
Definitions
• Paroxysmal AF– Under 7 days– 2 or more episodes
• Persistent AF– 7 days to 1 year
• Permanent AF– Over 1 year with/without intervention– Accepted for rate control
![Page 4: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/4.jpg)
Pathophysiology
Supraventricular ectopic focus with permissive atrial substrate
Younger
Myocytes in pulmonary veinsDrugs and alcoholMetabolic abnormalitiesElectrolyte abnormalitiesSepsis
Older
LVH/aortic stenosisAtrial ischaemia and IHD
Mitral stenosis/incompetence
HypertensionCatecholamine drive
Sepsis
![Page 5: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/5.jpg)
Two Considerations
• Reduce ventricular rate– Cardiovert– Slow
• Prevent thromboembolism– Cardiovert – Anticoagulate
![Page 6: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/6.jpg)
Treatment Strategies
Rhythm Control
YoungerFirst presentation
Underlying cause treatedSymptomaticHeart Failure
Rate Control
OlderCoronary artery disease
Contraindications to cardioversion
Previous failure
Paroxysmal PermanentPersistent
Rhythm Control
Rate ControlFailure
Symptoms Persist
![Page 7: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/7.jpg)
Rhythm Control – Paroxysmal AF
• All need assessment for anticoagulation
• May need cardioversion (but aim to avoid)
• Pill in pocket may be appropriate (flecanide)
• Standard beta-blocker first line (bisoprolol)
• If failure:– CAD – Sotalol– LVD – Amiodarone
![Page 8: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/8.jpg)
Rhythm control – Persistent AF
Onset < 48 hours
Electrical
Outpatient Management
Emergency Department
Chemical
Amiodarone
Flecanide
Heparinise
Sotalol or Amiodarone
Failure likely?
Warfarinise
Rate Control
![Page 9: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/9.jpg)
Rate control – Persistent or Permanent
• All patients need assessment for anticoagulation
• Aim for rate under 100 (may need nothing)
• Beta-blocker of calcium channel antagonist
• Add digoxin if further control necessary
![Page 10: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/10.jpg)
Thromboembolism
• Ineffective atrial contraction• Venous pooling in atrial appendage• Embolism
![Page 11: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/11.jpg)
CHAD2Vasc
• Congestive Cardiac Failure• Hypertension• Age > 75 (2) > 65 (1)• Stroke/TIA/DVT/PE (2)• Vascular disease• Diabetes• Female 0 – Low risk
1 – Moderate risk
> 2 high risk
![Page 12: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/12.jpg)
European Society of Cardiology
High Risk
CVATIAVTE
Medium Risk
> 75HTN
EF < 35%DM
No Risk
Warfarin Aspirin
![Page 13: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/13.jpg)
Ablation/MAZE procedure
• 1:1000 death• 1:50 complications• 60% success
![Page 14: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/14.jpg)
Case 1
• 40, fit and healthy, normal ET, normal resting ECG
• Onset AF@135bpm 24 hours ago, first event• Haemodynamically stable• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then Aspirin 75mg
Pill in pocket
Flecanide 300mg
![Page 15: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/15.jpg)
Case 2
• 60, on carbimazole and bendroflumethiazide
• AF for 24 hours, otherwise normal examination
• All bloods normal including TFTsAnticoagulant?
Maintenance?
Cardioversion?
Heparin then warfarin
Bisoprolol
Electrical (not amiodarone)
![Page 16: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/16.jpg)
Case 3
• 28 fit and well, onset AF 3 hours ago• Mild symptoms, examination normal• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then aspirin
Pill in pocket
Not today, return starved tomorrow
![Page 17: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/17.jpg)
Case 4
• 89, SOB, tachycardic, febrile, cough• Raised WCC and ARF and
hypokalaemia
Anticoagulant?
Maintenance?
Cardioversion?
Probably
Review prior to discharge
Not until treated
![Page 18: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/18.jpg)
Case 5
• 80, hypertensive, smoker with COPD• Incidental finding, symptom free• Rate 110bpm
Anticoagulant?
Maintenance?
Cardioversion?
Warfarin
Diltiazem
No
![Page 19: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/19.jpg)
Case 6
• 50, AF 8 hours, ejection systolic murmur
• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then aspirin
Bisoprolol
Amiodarone
![Page 20: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/20.jpg)
![Page 21: Atrial Fibrillation Current Management Strategies.](https://reader035.fdocuments.us/reader035/viewer/2022062221/56649e2d5503460f94b1c630/html5/thumbnails/21.jpg)
Case 7
• 50, AF 8 hours, ejection systolic murmur
• Bloods normal
Anticoagulant?
Maintenance?
Cardioversion?
Heparin then aspirin
Bisoprolol
Amiodarone