Atrial Fibrillation

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Atrial Fibrillation

• Dr Nidhi Bhargava
• 8/10/13

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• Most Common sustained clinical arrhythmia
• Incidence rises with age- gt5 over the age 65-75

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Risk factors for AF

• Hypertension- accounts for 14 of AF in
  population
• Heart failure
• Male sex
• Diabetes
• Valvular
• MI
• LVH
• LVSD
• Left atrial dilatation
• Lone AF- with no structural or functional heart
  disease- 15

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Types of AF

• Paroxysmal or recurrent (intermittent and self
  terminating)
• 35-66 of all AF cases peak prevalence 50-69yrs
• At least a quarter may go progress to permanent
  AF
• Persistent (does not terminate spontaneously but
  may be effectively cardioverted)
• Permanent ( no longer reversible or reverses for
  brief interval only)

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Effects of AF

• Haemodynamic effects
• Loss of atrial contraction and AV synchrony
• Rapid ventricular rate
• Irregular ventricular rate

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Effects of AF

• Symptoms
• Palpitations
• Breathlessness
• Chest pain

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Effects of AF

• Thromboembolism
• Valvular AF -more so in pts.. with MS and AF (6
  per year)
• Non Valvular AF- 4-5 times increased risk of
  stroke overall
• Further increased risk if
• Previous stroke or TIA (20x increased risk)
• Age gt65, Hypertension and diabetes
• CAD, LV dysfunction and Left atrial dilatation
• lt65 yrs. risk 1 per annum

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Effects of AF

• Mortality- doubled in both sexes
• Increased risk of stroke 4-5 fold increase-
  further increase with age from 1.5 in sixth
  decade to 23.5 in the ninth decade

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Treatment

• Restoration of sinus rhythm
• Pharmacological cardioversion
• Electrical cardioversion
• External
• Internal

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Treatment

• Maintenance of sinus rhythm
• Drugs
• DDD pacing
• Ablation of AF triggers
• Surgery for AF
• Ventricular Rate Control
• Anticoagulation

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Treatment

• Cardioversion (pharmacological and electrical)
• Electrical cardioversion
• External and Internal
• External- under GA, success rate 65-90, 200-360J
• Internal- under sedation- percutaneous electrode-
  success rate 90
• Pharmacological cardioversion
• Most effective if administered within 24 hrs. of
  onset
• Flecainide most effective- 72-95
• Others include amiodarone , sotalol, propafenone
• Less effective in chronic AF- Amiodarone most
  effective
• At least 4 weeks of full anticoagulation
• Anticoagulation to e maintained for 4 weeks after
  successful cardioversion

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Treatment

• Maintenance of Sinus rhythm
• Drugs
• Flecainde and Propafenone (Class 1c)
• Sotalol better then propafenone
• Amiodarone most effective but multiple side
  effects
• Beta blockers- no date available
• Digoxin- no effect
• Pacing
• DDD pacing- reduce AF paroxysms
• Continuous atrial pacing-dual site or biatrial

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Treatment

• Focal Ablation
• Targets AF initiating foci located in proximal
  pulmonary veins
• Radiofrequency energy delivered
• Used for pts. with paroxysmal AF
• Pts. with chronic AF but can be successfully
  cardioverted at least for few seconds
• Under LA
• Success rate 70 in PAF and 50 in chronic AF

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Treatment

• Surgery for AF-Maze operation
• Ventricular rate control
• AV node ablation
• Drugs
• Digoxin- not negative inotropic but less
  effective
• Diltiazem, verapamil and beta blockers- more
  effective but negatively inotropic

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Case histories

• A 67 years old female with no risk factors
  presents with palpitations
• A 77 years old male with no risk factors is found
  to be in AF on routine examination
• A 98 years old male with AF on warfarin presents
  with haematuria and subsequently diagnosed with
  Ca bladder
• A 79 year old female with AF rate 120-140/min, on
  warfarin and digoxin, asthmatic and has severe
  reaction to verapamil-treatment options
• A 64 years old diabetic is in AF on routine
  examination