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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?
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