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  1. 1. Martin Siegfried, M.D Cardiologist at the CardioVascular Group/Gwinnett Medical Group Board Certified in Cardiovascular Diseases He is a Member of the American College of Cardiology Special interests include Coronary Artery Disease, Stress Testing, and Cardiac Echocardiography. Medical School: Thomas Jefferson University Residency: Emory University Hospital Fellowship: Emory University Hospital
  2. 2. A fib in Special Situations
  3. 3. Disclosures No financial disclosures
  4. 4. Post Op Afib
  5. 5. Post OP Possible causes Hypoxia Hypokalemia and hypomagnesemia Pericarditis Hyper-adrenergic state Inflammation
  6. 6. Cardiac Post OP Increasing age Preop AF Large LA Prior Cardiac surgery Mitral valve disease Chronic obstructive pulmonary disease (COPD) Increased hemoglobin A1c Poor physical activity in the year prior to surgery Caucasian race Obesity Lack of beta-blocker or ACE inhibitor Elevated BNP Severe right coronary artery stenosis Hypokalemia and hypomagnesemia
  7. 7. Post Op Post op CABG 15-40% Post op Valve 37-50% Post op CABG + Valve 60%
  8. 8. Clinical Implications Increased incidence of PO complications Longer hospital stay More likely to develop hypotension, pulmonary edema and CVA (3.3% vs. 1.4%) Lower in-hospital as well as long term survival Cost of care of PO AF $~10,000/patient
  9. 9. PostOp Timing Occurs by day 2 or 3 post op 15-30% convert within two hours and up to 80% in 24 hours The mean duration 11-12 hours and more than 90% in sinus rhythm 6-8 weeks post op 3 of 116 were still in AF at six weeks Various sources
  10. 10. Question 1 Mrs J. develops afib with generally controlled rates on post op CABG day 3. The next step in her management is? A) Synchronized Cardioversion B) Intravenous Amiodarone C) Beta-blockers and Anticoagulation D) Observation
  11. 11. Post OP Intra Operative Measures to Reduce Post Cardiac Surgery A fib Off-pump CABG Preservation of the anterior fat pad
  12. 12. You are asked to see a patient for pre-op clearance for CABG. Patient is a white male 76 years old with PMH of HTN and DM. Medications include apart from others metoprolol tartrate 50mg bid, lisinopril 10mg daily, ASA, Insulin. Exam: BP: 120/88 P-78 systemic exam normal. With regards prevention of postoperative AF, what is the next best step? A) No change, proceed with surgery B) Decrease lisinopril and increase metoprolol C) Add Amiodarone D) Add Digoxin Question 2
  13. 13. Post Op Prevention Beta-blockers, sotalol, amiodarone, atrial pacing all effective No compelling data supporting a preferred beta- blocker. Beta-blockers effective both pre and post op. Digoxin, Mg, Calcium Channel Blockers thought to be ineffective to prevent afib.
  14. 14. Question 3 Your 50yo patient pictured below underwent successful ablation for moderately disabling afib 8 months ago has a recurrence of afib. They do have diabetes and hypertension that are usually well controlled except upon arising. He snores. The next step is: A) Repeat ablation B) Find a more skillful Electrophysiologist C) Pulmonary consult/sleep study D) A visit to the Sarlacc
  15. 15. Obstructive Sleep Apnea and Afib
  16. 16. Obstructive Sleep Apnea Controlled studies have found an association between OSA and afib. There is a dose-response relationship with more severe OSA associated with higher incidence. Conversly 30-80% of afib patients have some form of OSA
  17. 17. Obstructive Sleep Apnea Post ablation patients have a 25% increased risk of recurrence of afib if they have untreated/undiagnosed OSA Ng CY, Liu T, Shehata M, Stevens S, Chugh SS, Wang X Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation. Am J Cardiol. 2011 Jul;108(1):47-51. Epub 2011 Apr 29.
  18. 18. Obstructive Sleep Apnea The good news: CPAP Treatment of OSA reduces afib recurrence in observational studies 82% untreated vs 42% treated 63% untreated vs 28% treated The effect of non-CPAP therapies (meds, oral appliances, surgery, trach) is not known
  19. 19. Heart Failure and Afib
  20. 20. Heart Failure Both afib and CHF increase in the population with age. It has been established that each predisposes the patient to the other condition. HF causes atrial stretch leading to arrythmia AF causes diminished cardiac output and may also cause LV dysfunction
  21. 21. Heart Failure
  22. 22. Question 4 Heart failure patients who have their rhythm normalized have lower mortality than those who remain in AF (but have controlled rates) A) True B) False
  23. 23. Heart Failure AF CHF 1376 patients followed for 37 mo CV death 27% rhythm-control 25% rate-control death from any cause 32% 33% stroke 3% 4% worsening heart failure 28% 31% There were also no significant differences favoring either strategy in any predefined subgroup. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL, Atrial Fibrillation and Congestive Heart Failure Investigators Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358(25):2667.
  24. 24. An 80YO male with a prior history of afib is scheduled for a work in appointment due to a recurrance of arrythmia. He has been stable on amiodarone and warfarin for 3 years. He also reports wt loss, insomnia, and tremor. What lab testing do you order? A) CBC B) Chem-7 C) BNP D) TSH Question 5
  25. 25. Hyperthyroidism and Afib
  26. 26. Hyperthyroidism In a prospective study, 2007 hyperthyroid subjects 60 years of age who did not have AF were followed for 10 years. 28% hyperthyroid patients versus 11% euthroid patients developed afib Sawin CT, Geller A, Wolf PA, Belanger AJ, Baker E, Bacharach P, Wilson PW, Benjamin EJ, D'Agostino RB Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med. 1994;331(19):1249.
  27. 27. Hyperthyroidism >5-fold higher likelihood for the presence of atrial fibrillation in either subclinical and overt hyperthyroidism Auer J, Scheibner P, Mische T, Langsteger W, Eber O, Eber B Subclinical hyperthyroidism as a risk factor for atrial fibrillation. Am Heart J. 2001;142(5):838.
  28. 28. Hyperthyroidism Hyperthyroid patients experience increased: premature supraventricular depolarizations atrial premature contractions (APCs non-sustained supraventricular tachycardias heart rate and reduced heart rate variability. decreased parasympathetic tone.
  29. 29. Question 6 The next step in the therapy is to? A) stop amiodarone B) arrange for cardioversion C) both A and B D) consult endocrinologist re methizamole
  30. 30. Hyperthyroidism
  31. 31. Hyperthyroidism ~55-75% of patients with atrial fibrillation due to hyperthyroidism and no other underlying cardiac valvular disease will return to sinus rhythm within three to six months after treatment of the thyrotoxic state
  32. 32. Question 7 Caffeine ingestion increases risk of developing afib? A) True B) False
  33. 33. Caffeine and Afib
  34. 34. Caffeine Despite the theoretical relationship between caffeine and arrhythmogenesis, there is no evidence, in humans, that ingestion of caffeine in doses typically consumed can provoke AF or any other spontaneous arrhythmia Mehta A, Jain AC, Mehta MC, Billie M Caffeine and cardiac arrhythmias. An experimental study in dogs with review of literature. Acta Cardiol. 1997;52(3):273.
  35. 35. Caffeine 22 patients with ventricular tachycardia or fibrillation underwent EP testing before and one hour after coffee ingestion (275 mg of caffeine). Arrythmogenesis: unchanged in 10 patients increased in 6 reduced in 6 Rhythm severity unchanged in 17 patients Increased in 2 patients Reduced in 3 patients
  36. 36. Caffeine Meta-analysis of >100,000 individuals, caffeine exposure was not associated with an increased risk of atrial fibrillation. Caffeine toxicity can be associated with arrhythmic events, especially in patients with underlying cardiac disease Caldeira D, Martins C, Alves LB, Pereira H, Ferreira JJ, Costa J Caffeine does not increase the risk of atrial fibrillation: a systematic review and meta-analysis of observational studies. Heart. 2013 Oct;99(19):1383-9.
  37. 37. Question 8 A frail 75YO who lives independently is newly diagnosed with afib. She has a prior history of htn and IDDM. She is mildly symptomatic. Her rate is controlled. Work up reveals mild MR, normal EF, normal TSH and no ischemia. She ambulates with a walker and owns 7 cats. What should you do? A) Start Amiodarone and Coumadin B) Aspirin only, too high risk for full anticoagulation C) Start Coumadin or one of the new agents D) Arrange for cardioversion
  38. 38. Falls and Afib
  39. 39. Falls 1 of 3 adults > 65, fall each year (1/2 mention it to their healthcare providers) Among older adults, falls are the leading cause of both fatal and nonfatal injuries In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments and more than 734,000 of these patients were hospitalized In 2013, the direct medical costs of falls, adjusted for inflation, were $34 billion
  40. 40. 20-30% of patients who fall suffer moderate to severe injuries (lacerations, hip fractures, and head trauma) Leading cause of traumatic brain injuries (TBI) 50% of fatal falls are secondary to TBI Among older adults most fractures are caused by falls Falls
  41. 41. Question 9 Which agent results in less intracranial hemor


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