atrial fibrillation - meity ardiana, md, fiha.pdf

CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

Meity Ardiana

Putri Rachmawati Dewi


Atrial Fibrillation (AF) affects 1–2% of thepopulation, and this figure is likely to increase in thenext 50 years

The average age of patients between 75 and 85 years

AF is associated with a five-fold risk of stroke and athree-fold incidence of congestive heart failure, andhigher mortality.

Pre

vale

nce,

perc

ent

Age, years

women men


Disorganised electrical and mechanical activity thatoriginates in the atria with an irregular response

Characteristics of AF :

ESC 2010

Heart Rate

• A : > 300 bpm• V : slow to rapid

Rhythm

Irregularly irregular

P-Wave

• No distinct P waves• Fibrillatory

Fibrillationwaves

Irregular R-Rinterval


Underlying Etiologies of Atrial Fibrillation

AHA 2014


Classification of AF

ESC 2010


1. Focal Mechanisms

2. The multiple wavelet hypothesis

The pulmonary veins (PVs) have astronger potential to initiate andperpetuate atrial tachyarrhythmias

AF is perpetuated by continuousconduction of several independentwavelets propagating through the atrialmusculature

Markides, 2003; Iwasaki 2011


All patients History

Physical examination

ECG

Echocardiogram

Thyroid function

Selected patients

Holter monitor

Invasive procedure


Symptoms vary greatly among individuals andinclude: anxiety, palpitations, dyspnea, dizziness,chest pain, and fatigue/weakness, irregular heartrate (Porth, 2005).

EHRA = European Heart Rhythm Association


Physical examination

Irregular pulse, pulsus deficit

valvular disease,

Exophthalmos


NICE Guideline 2014

Transthoracic Echocardiography(TTE)

TransoesophagealEchocardiography

(TOE)• Baseline echocardiogram is

important for long-termmanagement

• Rhythm-control strategy is beingconsidered

• High risk or a suspicion ofunderlying structural/functionalheart disease

• Refinement of clinical riskstratification for antithrombotictherapy is needed

• When TTE demonstrates anabnormality that warrants furtherspecific assessment

• TTE is technically difficult and/orof questionable quality and wherethere is a need to exclude cardiacabnormalities

• TOE-guided cardioversion isbeing considered


ESC 2010

GOALS• Hemodynamic

stabilization• Ventricular

rate control• Prevention of

emboliccomplication


Rate Control

AHA/ACC/HRS Atrial Fibrillation Guideline 2014

ESC Guideline 2010


Rate Control AgentsDrug Classes Drug Loading Dose Maintenance Dose

Calcium ChannelBlockers (non-dihydropyridine)-initial DOC

Diltiazem 10 mg IV over 2minutesCan repeat up to 20mg IV

30 mg PO q6 hrs(can transition tolong acting)Can use 10 mg IVq6 hrs prn

Beta Blockers-initialDOC

Metoprolol 5 mg IVP q5min x3doses

25 mg PO BID, canuptitrate to 100mgPO BID

OtherDigoxin 0.5 mg IV loading

dose0.25mg IV in6 hrs0.25mg IV 6hrs after

0.125 mg PO QD

Other Amiodarone 150 mg IV/10 min1mg/minx 6 hrs0.5 mg/min x 18hrs

100-200 mg PO QD


Rhythm control

ESC 2012


RATECONTROL

RHYTHMCONTROLVS

THE TRIALS• AFFIRM STUDY (2002)• RACE (2002)• PAF (2000)• STAF (2003)• HOT CAFÉ (2004)• RACE II (2010)

No differences in quality of life withrhythm control compared with rate control

Knight, et al, Practical Rate and Rhythm Management of Atrial Fibrillation, January 2010 ed.


RATECONTROL

RHYTHMCONTROLVS

• Persistent AF• Less symptomatic• Age ≥ 65 years old• Hypertension• No history of HF• Previous failure of

antiarrhytmic drug• Patient preference

• Paroxysmal AF or newlydetected AF

• More symptomatic• Age < 65 years old• No hypertension• HF clearly exacerbated

by AF• No previous failure of

antiarrhytmic drug• Patient preference

Frankel, 2013


Antithrombotic management

CHA2DS2-VASc : congestive heart failure, hypertension, age ≥75 ,diabetes, stroke vascular disease, age 65–74, and sex category(female)


ESC 2012 Atrial FibrillationGuidelines Update: Risk Assessment

Score CHA2DS2-VASc Risk Anticoagulation Considerations0 Low Aspirin (81-325 mg) daily or none

1 Moderate Aspirin daily or warfarin (INR to 2.0-3.0)or dabigatran (Pradaxa) or rivaroxaban(Xarelto) or apixaban (Eliquis), dependingon factors such as patient preference

2 or greater Moderate orHigh

Warfarin (INR 2.0-3.0) ordabigatran (Pradaxa) orrivaroxaban (Xarelto) or apixaban(Eliquis)


Importance of the HAS-BLED Score

Hypertension (> 160 mm Hg systolic) 1

Abnormal renal or hepatic function 1-2

Stroke 1

Bleeding history or anemia 1

Labile INR (TTR < 60%) 1

Elderly (age > 75 years) 1

Drugs (antiplatelet, NSAID) or alcohol 1-2

High risk (> 4%/year) > 4Moderate risk (2-4%/year) 2-3Low risk (< 2%.year) 0-1

Pisters R, et al. Chest 2010; 138: 1093.Lip GYH, et al. J Am Coll Cardiol 2010; 57: 173.

Weight (points)

Risk Score for Predicting Bleeding inAnticoagulated Patients with Atrial Fibrillation


Flowchartanticoagulation

therapy


AHA/ACC/HRS Atrial Fibrillation Guideline 2014

ESC Guideline 2010


Limitation of Warfarin

Slow onset of action

Genetic variation in metabolism

Multiple food and drug interactions

Narrow theurapeutic index


New Oral Anticoagulants (NOACs)

Dabigatran Rivaroxaban Apixaban

• RELY trial• Direct thrombin

inhibitor• 110 mg b.i.d and

150 mg b.i.d doses

• ROCKET-AF trial• Direct factor Xa

inhibitor• 20 mg once a day

• AVERROES trial• ARISTOTLE trial• Direct factor Xa

inhibitor• 5 mg b.i.d. with a

dose adjustmentto 2.5 mg b.i.d


Comparison Overview of NewAnticoagulants with Warfarin

Features Warfarin New Agents

Onset Slow Rapid

Dosing Variable Fixed

Food effect Yes No

Drug interactions Many Few

Monitoring Yes No

Half-life Long Short

Antidote Yes No


The technique of ablation :To target individual ectopic withinthe PV to circumferentialelectrical isolation of the entirePV musculature

Catheter ablation should bereserved for patients withAF which remains symptomaticdespite optimal medical therapy,including rate and rhythm control.

Ablation


Quality of life and exercise capacity are impaired inpatients with AF.

Patients with AF have a poorer quality of lifecompared with healthy controls, the generalpopulation, or patients with coronary heart diseasein sinus rhythm.

Hospitalisation can be limited to highly symptomaticpatients, those with structural heart disease, had anembolic event or are at high risk ofthromboembolism, and patients with failure of ratecontrol in the emergency department


Atrial fibrillation (AF) is the most common sustainedcardiac arrhythmia, occurring in 1–2% of the generalpopulation.

AF confers a 5-fold risk of stroke, and one in five of allstrokes is attributed to this arrhythmia.

AF is defined as a cardiac arrhythmia with the followingcharacteristics: The surface ECG shows ‘absolutely’irregular RR intervals , there are no distinct P waves onthe surface ECG, the atrial cycle length (when visible), isusually variable.

The management of AF including the rate controlstrategy, rhythm control strategy, cardioversion andantithrombotic therapy


Procedures: Ablation A catheter is inserted into the femoral artery to

the area of heart muscle where there's anaccessory (extra) pathway.

The catheter is guided using fluoroscopy. The physician is able to see the exact area on the

heart that is causing the accessory pathway Radiofrequency energy is transmitted to the

pathway and destroys the selected heart musclecells in a very small area (about 1/5 of an inch).

(American Heart Association, 2010).


ESC 2012

atrial fibrillation - meity ardiana, md, fiha.pdf

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