Carlos CalleMuller MD Cardiac Electrophysiology 7348559448 Objectives To recognize the risks for patients with atrial fibrillation To familiarize with the management of atrial fibrillation Atrial fibrillation AF is the most common cardiac arrhythmia ID: 914961
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Slide1
Atrial FibrillationUpdate for Primary Care
Carlos Calle-Muller, MDCardiac Electrophysiology734-855-9448
Slide2Objectives
To recognize the risks for patients with atrial fibrillationTo familiarize with the management of atrial fibrillation
Slide3Atrial fibrillation (AF) is the most common cardiac arrhythmia
Electrocardiographic characteristicsThe RR intervals follow no repetitive pattern. They have been labeled as "irregularly irregular.“While electrical activity suggestive of P waves is seen in some leads, there are no distinct P waves - Atrial rate greater than 300 beats per minute.
Slide4Slide5Outline
EpidemiologyMechanismsClinical diagnosis Medical management updatesInvasive management updatesUpdates in stroke preventionQuestions
Slide6Epidemiology
Atrial fibrillation (AF) affects around 2% of the general population It is the most prevalent cardiac arrhythmia.
Slide7Slide8Slide9The incidence of AF increases with age and structural heart disease
Slide10Epidemiologic features of chronic atrial fibrillation – The Framingham study
Kannel et al. N Engl J Med 1982; 306:1018-1022
Slide11Mechanisms of atrial fibrillation
There are 3 widely held theories:Multiple random propagating wavelets.Focal electrical discharges.
Localized reentrant activity with
fibrillatory
conduction (Rotors).
Slide12Truth is:
We do not have a clear understanding of the pathophysiology behind Atrial Fibrillation.Especially persistent atrial fibrillation.
Slide13Schotten
. Physiol Rev. 2011; 91: 265-325
AFNET registry
Age >75, HTN, DM, CM, HF, valve disease
Slide14Clinical Diagnosis
Typical symptoms:palpitations tachycardia fatigueweakness Dizziness
reduced exercise capacity
dyspnea
More severe symptoms:
angina
presyncope, infrequently syncope
embolic event
heart failure
Slide15Precipitating causes: Exercise Emotion (stress)
AlcoholPresence of the following disease associations: Cardiovascular or cerebrovascular disease Diabetes Hypertension Chronic obstructive pulmonary disease Obstructive sleep apnea
Potentially reversible causes (
eg
, hyperthyroidism, excessive alcohol ingestion)
Slide16Diagnostic work up
Event monitorTo determine presence of AFLength of monitoring based on symptom reportEchocardiogramTo evaluate cardiac function (LV ejection fraction)
To evaluate chamber size (specially LA size)
Treadmill EKG test
To evaluate symptoms if they are present during exertion.
Slide17Slide18Slide19Slide20Classification
Slide21Medical Management
Atrial Fibrillation
Anticoagulation
(based on risk factors)
Rhythm Control
Rate Control
Modifiable risk factors
TSH
OSA
Obesity
Alcohol
Slide22Stroke risk factors
Slide23Slide24JACC 2014
Slide25Slide26Slide272019 Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
Slide282019 Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
Slide29LAA Occluder Device
WATCHMAN device
One-time implant that does not need to be replaced
Transfemoral Access:
Catheter advanced to the LAA via the femoral vein
Does not require open heart surgery
General anesthesia (typical)
1 hour procedure (typical)
Slide30Slide312019 Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
Slide32AF Management: Rate vs Rhythm
AFFIRM – no mortality difference between rate and rhythm control. The potential benefit of sinus rhythm may have been negated by the proarrhythmic effects of antiarrhythmic drugs.
Drugs were effective in maintaining sinus rhythm in only 30% of patients during the trial.
Slide33Rate vs Rhythm
The decision to adopt a rhythm or rate control strategy is often dictated by:
Presence of
symptoms
associated with atrial fibrillation (may have subtle symptoms). These more subtle symptoms are sometimes only realized after restoration of sinus rhythm, which is why many physicians will at least offer a rhythm control approach to new onset AF patients
Development of
cardiomyopathy
thought secondary to the arrhythmia.
Slide34Medications
Rate control:Beta BlockersCalcium channel blockers (diltiazem, verapamil)DigoxinRhythm control (antiarrhythmics):
Class
Ic
: Flecainide, Propafenone (can not use in CAD, low EF)
Class III:
Sotalol (avoid in low EF) – risk of
Torsades
Dronaderone
(can not use in HF)
Dofetilide
– Higher risk of
Torsades
Amiodarone
Slide35Invasive Management
Ablation can be performed with Freezing (
Cryo
) or Burning (RF)
Similar outcomes
Slide36Of 45 patients, ectopic beats originated in atrial muscle in 4 patients and in the pulmonary veins in 41 patients
Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.
Haïssaguerre
et al. N
Engl
J Med. 1998 Sep 3; 339(10):659-66.
Slide37Surgical Maze Procedure
James L. Cox. The first Maze procedure. 1987
Slide38Convergent Hybrid Ablation
Slide39Pulsed Field Ablation
New ablation technology that is soon to be approved.
Good results
Slide40Take home points
Atrial fibrillation is the most common arrhythmia and is a common cause of strokeBoth stroke & bleeding risks should be considered when choosing an anticoagulation strategyRhythm control is considered in patients with symptomatic AF, cardiomyopathy.
Catheter ablation is considered when antiarrhythmic therapy fails to control symptoms. After failing one antiarrhythmic.