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 Atrial Fibrillation Who is at risk for atrial fibrillation?  Atrial Fibrillation Who is at risk for atrial fibrillation?

Atrial Fibrillation Who is at risk for atrial fibrillation? - PowerPoint Presentation

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Uploaded On 2020-04-03

Atrial Fibrillation Who is at risk for atrial fibrillation? - PPT Presentation

lt1 of individuals aged 60 to 65 years 8 to 10 of individuals aged gt80 years Men more than women White persons more than black persons Presence and severity of underlying heart disease increases risk ID: 774923

atrial fibrillation patients control atrial fibrillation patients control rate risk clinicians heart warfarin anticoagulation rhythm therapy cardioversion drugs disease

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Presentation Transcript

Slide1

Atrial Fibrillation

Slide2

Who is at risk for atrial fibrillation?

<1% of individuals aged 60 to 65 years

8% to 10% of individuals aged >80 years

Men more than women

White persons more than black persons

Presence and severity of underlying heart disease increases risk

Sleep-disordered breathing

Hypertension

Slide3

What symptoms and signs should cause clinicians to suspect atrial fibrillation?

Palpitations and chest pains (younger patients)

Fatigue and shortness of breath (elderly)

Faster-than-expected heart rate

“Irregularly irregular” time between heart sounds

Peripheral pulses that vary irregularly in rate, amplitude

Atrial fibrillation may be asymptomatic

Slide4

Is a single electrocardiogram sufficient to diagnose or exclude atrial fibrillation?

Yes, a diagnosis is possible if the ECG is recorded during the arrhythmia, but no, a normal rhythm doesn’t exclude AF

If AF suspected, monitor longer with

Holter monitor

Patch monitor

Electrocardiographic loop recorder

Other ways to identify atrial fibrillation

Implanted pacemakers

Implantable defibrillator-cardioverters with atrial leads

Subcutaneous implanted monitors

Slide5

Atrial fibrillation with rapid ventricular rate

Slide6

What is the role of history and physical examination?

To identify symptom frequency, severity, and duration

To identify underlying causes

Structural heart disease

Other causes and risk factors

Pulmonary disease, hyperthyroidism

Use of adrenergic drugs, other stimulants, alcohol

Diabetes, obesity, sleep-disordered breathing

Family history of first-degree relatives with atrial fibrillation

Slide7

What other electrocardiographic arrhythmias can be confused with atrial fibrillation?

Sinus rhythm with frequent premature atrial contractions

Atrial flutter

Atrial tachycardia

The following electrocardiographic findings identify atrial fibrillation and help distinguish it from other arrhythmias

Irregular ventricular rhythm without recurring pattern

Absence of P waves

If the diagnosis is uncertain, examine long recordings from multiple leads

Slide8

Sinus rhythm with frequent premature atrial contractions

Slide9

Atrial flutter

Slide10

How should clinicians classify atrial fibrillation?

Paroxysmal: Episodes spontaneously terminate within 7 days (often within 24 hours)

Persistent: Episodes last >7 days and require an intervention to restore sinus rhythm

Long-standing persistent: Continuous atrial fibrillation for >12 months

Permanent: Interventions to restore sinus rhythm have either failed or have not been attempted

Same patient may be classified into different categories at different times

Slide11

What laboratory studies should clinicians obtain in patients newly diagnosed with atrial fibrillation?

Serum electrolytes and TSH

Blood tests for renal and hepatic function

Fecal occult stool test (before starting anticoagulation)

Transthoracic echocardiography

Identify structural heart disease

Identify cardiomyopathy

Transesophageal echocardiography can rule out atrial clot when transthoracic images are inadequate and cardioversion is planned

Tests may be warranted for PE, acute MI, acute HF

Slide12

What underlying conditions should clinicians look for?

Structural heart disease

Atrial fibrosis

Predisposing conditions

Acute illness, such as acute MI, PE, thyrotoxicosis

Use of adrenergic drugs, other stimulants, alcohol

Recent cardiac or thoracic surgery

Other types of major surgery, severe illness

Obesity and sleep apnea

Family history of first-degree relatives with atrial fibrillation

Slide13

CLINICAL BOTTOM LINE:

Diagnosis...

Typical symptoms

Palpitations, shortness of breath, exercise intolerance

Some patients are asymptomatic

ECG during episode: only way to confirm diagnosis

Longer monitoring may be helpful (loop recorder)

Labs: to r/o underlying disorders or contraindications to therapies

Echocardiogram: to look for structural heart disease

Slide14

Why should atrial fibrillation be treated?

To reduce symptoms

Although some patients are asymptomatic

Other patients have disabling symptoms

To prevent thromboembolism

Stroke is the most important event

Especially in older patients with nonvalvular atrial fibrillation

To prevent cardiomyopathy

Persistent tachycardia can lead to cardiomyopathy

Slide15

When should clinicians consider immediate cardioversion?

Most patients do not require immediate cardioversion

Cardioversion can be useful in select circumstances

Decompensated HF, severe angina, acute infarction, hypotension, high risk for acute stroke

Patients with atrial fibrillation and extreme tachycardia, for example, with Wolff-Parkinson-White syndrome

Duration <48h in new-onset atrial fibrillation, because clot is less likely

Cardioversion can make anticoagulation unnecessary

Slide16

Which patients should clinicians consider hospitalizing?

Uncertain or unstable underlying arrhythmia

Acute MI, altered mental status, decompensated HF, or hypotension

Intolerable symptoms despite hemodynamic stability

For elective cardioversion when a monitored, outpatient setting is not availabl)

For acute anticoagulation if very-high risk for stroke

Telemetry monitoring during initiation of certain drugs

Procedures such as electrophysiological studies, cardiac catheterization, and catheter or surgical ablation and placement of pacemakers or implantable defibrillators

Slide17

Should clinicians attempt rate control or rhythm control?

Rhythm control

Clinicians traditionally have preferred

Does not improve mortality, frequency of stroke or hospitalization, or QOL compared to rate control

May be useful in patients with severe symptoms and in younger patients without structural heart disease

Rate control

Easier to accomplish

Prevents exposure to potential adverse effects of antiarrhythmic agents

Slide18

What strategies should clinicians consider for rate control in patients with rapid atrial fibrillation?

Drug therapy: to control ventricular rate in all patients, even if rhythm control is ultimately the goal

Traditional target: 60 to 80 beats/min at rest and 90 to 115 beats/min during moderate exercise

To decrease AV nodal conduction (first-line): β-blockers, nondihydropyridine calcium-channel antagonists

To slow conduction through AV node (but not first-line monotherapy for rate control): digitalis, amiodarone

To reduce ventricular response if other agents have failed: amiodarone (difficult to justify due to associated toxicities)

Slide19

What strategies should clinicians consider for rhythm control?

Electrical cardioversionWhen patient is hemodynamically unstableDrug therapySide effects should guide choice of antiarrhythmic drugsWhen atrial fibrillation >48h in durationAchieve rate control and adequate anticoagulation first Serum potassium should be >4.0, serum magnesium >1.0, and ionized calcium levels >0.5 mg/dL

(Continued)

Slide20

Class

Ic

drugs,

such as flecainide and

propafenone

,

are useful

in patients without

significant structural heart disease

Other

class I drugs

are used

infrequently because of

noncardiac

side effects and concern for

proarrhythmia

Class III

drugs,

such

as

sotalol

and

dofetilide

,

can

prolong the QT interval and cause

torsades

de pointes

Amiodarone

: permanent liver and lung toxicity is dose- and duration-dependent

Dronedarone

: similar in structure to

amiodarone

but without iodine and with less antiarrhythmic efficacy

Contraindicated for decompensated CHF and for permanent atrial fibrillation

Slide21

Drug Therapy for Rate and Rhythm Control in Atrial Fibrillation

Rate-Controlling AgentsBeta-BlockersMetoprololPropranololEsmololPindololAtenololNadololCalcium-channel blockersVerapamilDiltiazemCardiac glycosideDigoxin

Antiarrhythmic agents Class Ia

Procainamide

Quinidine gluconate

Disopyramide

Antiarrhythmic agents Class Ic

Flecainide

Propafenone

Antiarrhythmic agents Class III

Ibutilide

Amiodarone

Sotalol

Dofetilide

Slide22

When should clinicians use antiarrhythmic drugs to prevent recurrence?

Only modestly effective in prolonging the time to recurrence

One study found amiodarone reduced recurrence more effectively than sotalol or propafenone

Therapy considered effective if it

Reduces the frequency of episodes

Reduces the frequency of symptoms

Slide23

When is anticoagulation indicated?

When the risk for thromboembolism exceeds the risk for serious bleeding from anticoagulation

When the CHA

2

DS

2

-VASc is

≥2

Guidelines recommend anticoagulation for all patients with documented atrial fibrillation (symptomatic or asymptomatic) and ≥2

CHA

2

DS

2

-VASc risk factors

Anticoagulation considered reasonable but not mandatory when the score is 1

Slide24

CHA2DS2 VASc Score

Characteristic, PointsCongestive heart failure, 1Hypertension, 1Age ≥ 75 y, 2Diabetes mellitus, 1Stroke/transient ischemic attack, 2

Guidelines for Thromboembolic Prophylaxis

CHA2DS2-VASc Score, Recommendation0, No therapy required1, No therapy required but treatment with aspirin or an anticoagulant is also reasonable≥ 2, Anticoagulate with warfarin, dibagatrin, rivoxaraban, or edoxaban

Slide25

What anticoagulation regimens should clinicians use?

Warfarin is the traditional choice

Warfarin reduces strokes better than antiplatelet therapy and is noninferior to the newer non-vitamin K-dependent anticoagulants

When the risk for thromboembolism is lower, start warfarin without loading dose or concurrent heparin

When the risk for thromboembolism is higher, hospitalize and give unfractionated heparin until warfarin target levels are achieved

Slide26

Cardioversion

Give warfarin for ≥3-4 weeks before to achieve INR 2.0-3.0 if the duration of atrial fibrillation is undetermined or ≥48h, and continue for ≥4 weeks after cardioversion

If non-vitamin K-dependent oral anticoagulants are used instead, give for 3-4 weeks before and continue for ≥4 weeks

Alternative approach: transesophageal echocardiography

If left atrial clot is not present, give 48h unfractionated heparin or non-vitamin K-dependent oral anticoagulant before cardioversion, then 4 weeks after cardioversion

If clot is present, give 4 weeks anticoagulation before cardioversion and repeat transesophageal echocardiogram

Slide27

Aspirin 325 mg/d Can Be an Alternative

Patient cannot take warfarin or non-vitamin K-dependent oral anticoagulant

No previous stroke or transient ischemic attack

≤65 years of age

No hypertension, diabetes, or heart failure

Aspirin plus clopidogrel prevents more strokes than aspirin alone, but this combination is not as effective as warfarin and has an equivalent bleeding risk

Slide28

Non-vitamin K-dependent Anticoagulants

Noninferior alternatives to warfarin for preventing thromboembolism

Don

t require recurrent blood tests to assess INR, minimal potential for drug-drug interaction, and not influenced by diet

Act rapidly

Guidelines for renal dose adjustment

Lower risk than warfarin for intracranial hemorrhage

Contraindicated with mechanical heart valves, but can be used with native valve disease

Management easier when temporarily discontinued, but antidotes are more limited than with warfarin

Slide29

When should clinicians consider nondrug therapies?

AV nodal ablation therapy

When pharmacologic rate control cannot be achieved

Requires pacemaker insertion, can lead to progressive LVD

Atrial fibrillation ablation therapy

For highly symptomatic patients with paroxysmal or persistent atrial fibrillation in whom an attempt at antiarrhythmic drug therapy has failed

Not a cure

Occluding the left atrial appendage is a alternative for stroke prevention when the risk from anticoagulation is too high

Slide30

How should clinicians monitor patients?

Frequency may depend on warfarin monitoring

Determine whether symptoms are adequately controlled

Measure resting and exercise heart rates to determine the adequacy of therapy

Laboratory tests as needed to assess drug effectiveness and toxicity

Switch patients who have not improved on rhythm-control drugs to rate-control drugs, or consider nonpharmacologic therapy

Slide31

CLINICAL BOTTOM LINE:

Treatment...

Goals: reduce symptom frequency and severity, prevent stroke, prevent tachycardia-related cardiomyopathy

CHA

2

DS

2

-VASC score: to select patients for anticoagulation

Focus on rate control (target resting rate: 60-110 beats/min)

Attempt rhythm control if patients do not respond to rate control or do not tolerate atrial fibrillation

Atrial fibrillation ablation and AV nodal ablation therapy may be appropriate when patients remain highly symptomatic

Closure of the left atrial appendage is an alternative for thromboembolic protection

Slide32

What's new in this update?

Dronedarone is contraindicated for permanent atrial fibrillation

CHA

2

DS

2

-VASC score has become the standard for predicting thromboembolic risk

Non-vitamin K-dependent oral anticoagulants are approved as alternatives to warfarin for thromboembolic prophylaxis

Reversal agent for dabigatran is now available

Catheter ablation of parts of the atrium where atrial fibrillation begins has become a more widely accepted intervention

Closure of left atrial appendage with atrial occlusion device is approved for patients at risk of stroke who are unable to take systemic anticoagulation