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Atrial fibrillation ksaus hs 2019
Atrial fibrillation is the most common arrhythmia and increases mortality risk. It is classified as paroxysmal, persistent, or permanent based on duration. The CHA2DS2-VASc score is used to assess stroke risk and determine need for anticoagulation. Treatment focuses on rate control with medications like calcium channel blockers or cardioversion for hemodynamic instability. Anticoagulation is recommended for CHA2DS2-VASc score over 2 to prevent stroke.
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Introduction to atrial fibrillation (AF), its definitions, and its significant impacts on mortality.
The rise in the prevalence of atrial fibrillation in America, projected from 6.4 million in 2015 to 11.4 million by 2035.
Key antithrombotic recommendations for AF management, including CHA2DS2-VASc scoring for stroke risk.
Presentation of a case detailing patient symptoms and management decisions regarding atrial fibrillation.
Indications and procedures for urgent cardioversion in hemodynamically unstable AF patients.
Management of stable AF with a focus on rate and rhythm control strategies, including various agents.
Discussion of WPW syndrome and management strategies for patients with rapid AF responses.
Details about pre-excitation and the historical context of WPW syndrome and its diagnosis.
Clinical case presentations highlighting varied patient demographics and symptoms of AF.
Clinical case presentations highlighting varied patient demographics and symptoms of AF.
Information on non-vitamin K-dependent anticoagulants and when to consider non-drug therapies.
Guidelines for monitoring AF patients and primary management goals to reduce symptoms and risks.Final thoughts on AF management, including treatment options and study findings.
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Similar to Atrial fibrillation ksaus hs 2019
Atrial fibrillation ksaus hs 2019
- 1. ATRIL FIBRILLATION Ihab SulimanMBBS ECFMG MRCP MRCP spec (Endo and DM) AB cv CBNC FESC 2019
- 2. Definitions of AF:A Simplified Scheme Term Definition Paroxysmal AF AF that terminates spontaneously or with intervention within 7 d of onset. Episodes may recur with variable frequency. Persistent AF Continuous AF that is sustained >7 d. Long-standing persistent AF Continuous AF >12 mo in duration. Permanent AF The term “permanent AF” is used when the patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm. Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of AF. Acceptance of AF may change as symptoms, efficacy of therapeutic interventions, and patient and clinician preferences evolve. Nonvalvular AF AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. AF indicates atrial fibrillation.
- 3. AF The MostCommon sustainable Arrhythmia. Patients with AF have their Mortality Doubled. There is associated Mortality and Morbidity Like Stroke. Increases with Age As much as 30%-50% of heart failure Have AF
- 4. Atrial Fibrillation 2015 6.4million Americans Copyright © 2016
- 5. Atrial Fibrillation 2035 11.4million Americans Copyright © 2016
- 6. Key Points fromthe 2014 Guideline Antithrombotic rx: individualize- benefit vs risk and patient preference Antithrombotic therapy regardless of whether AF pattern is permanent, persistent, or episodic Non-valvular AF embolic risk: CHA2DS2-VASc Mechanical heart valve + AF = warfarin Non-valvular AF indications for oral anticoagulation are: Prior stroke Prior TIA CHA2DS2-VASc > 2 Copyright © 2016
- 7. CHADS2 Score Congestive heartfailure - 1pt Hypertension - 1pt Age > 75 - 1 pt Diabetes - 1pt Stroke or TIA - 2 pts 0 points – low risk 1-2 points – moderate risk > 3 points – high risk *Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001 Jun 13. 285(22):2864-70
- 8. CHA2DS2-VASc Congestive heart failure/LV dysfunction - 1pt Hypertension - 1pt Age > 75 - 2 pt Diabetes - 1pt Stroke or TIA - 2 pts Vascular disease (prior MI, PAD, aortic plaque) - 1pt Age 65-74 - 1pt Sex category (ie female gender) - 1pt *Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41(12):2731-8.
- 9. Anticoagulation Who do weanticoagulate? • CHA2DS2-VASc > 2 • Afib + prior stroke or TIA • Afib + mechanical valve: warfarin • Valvular afib Who do we NOT anticoagulate? • CHA2DS2-VASc = 0 Copyright © 2016
- 10. Case 1 A75 year old woman with PMHx of HTN, HLD and DM, CKD presents to ED for new onset dizziness, shortness of breath and palpitations that began 3 hours ago while patient was gardening in her lawn. She denies any associated chest pain and no actual loss of consciousness. Vital Signs: T: 37.5 C, BP 90s/60s (Baseline BP 115/80s), HR 140s-160s bpm and RR 24. A&O x3 with some facial grimmace. Cardiac exam is irregulary irregular without murmurs. Lungs CTAB. Remainder of exam unremarkable. She received a 2L bolus in the ED without increase in blood pressure
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- 12. What is thenext appropriate management for this patient? A) IV diltiazem B) Intubation C) Urgent Cardioversion D) IV pain control E) CT pulmonary angiogram
- 13. Indications for UrgentDirect Cardioversion Hemodynamic Instability: Patient with decompensated heart failure Active ischemia: if symptomatic with angina or evidence of ischemia/infarction on EKG Evidence of organ hypoperfusion (altered mental status, cold clammy skin, acute kidney injury)
- 14. Urgent Cardioversion ElectricalCardioversion: sedate patient and place setting on direct synchronization then shock Initial shock setting of 100J 200J 300J 360J until sinus rhythm returns Make sure you perform direct cardioversion with R wave synchronization to prevent an “R on T” phenomenon which can lead to V fib Restoration of normal sinus rhythm takes precedence over need for protection from thromboembolic risk Would recommend cardiology consult at this time
- 15. If Patient isHemodynamically Stable Goal is ventricular rate control (<100 bpm) and anticoagulation Resting HR goal should be 60-85 bpm in symptomatic patient Roughly 50% of patients with new onset AF will spontaneously convert to NSR spontaneously within 48 hours of onset Rate control or Rhythm control? AFFIRM trial and RACE trial No survival advantage in terms of stroke prevention rhythm control over rate control rate control Rate control agents Calcium Channel Blockers Beta blockers (caution in patients with reactive airway disease) Digoxin Amiodarone (for patients intolerant or unresponsive to other agents)
- 16. Rate Control Agents DrugClasses Drug Loading Dose Maintenance Dose Calcium Channel Blockers (non- dihydropyridine) -initial DOC Diltiazem 10 mg IV over 2 minutes Can repeat up to 20 mg IV 30 mg PO q6 hrs (can transition to long acting) Can use 10 mg IV q6 hrs prn Beta Blockers- initial DOC Metoprolol 5 mg IVP q5min x3 doses 25 mg PO BID, can uptitrate to 100mg PO BID Other Digoxin 0.5 mg IV loading dose0.25mg IV in 6 hrs0.25mg IV 6 hrs after 0.125 mg PO QD Other Amiodarone 150 mg IV/10 min 1mg/minx 6 hrs 0.5 100-200 mg PO QD
- 17. Case 2 22years old Syrian male previously Healthy came to ER with Rapid and fast palpitations. He is a Carpenter
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- 19. WPW and Pre-ExcitationSyndromes Recommendations COR LOE Prompt direct-current cardioversion is recommended for patients with AF, WPW syndrome, and rapid ventricular response who are hemodynamically compromised. I C Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited AF and rapid ventricular response who are not hemodynamically compromised. I C Catheter ablation of the accessory pathway is recommended in symptomatic patients with pre-excited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction. I C Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium channel antagonists (oral or intravenous) in patients with WPW syndrome who have pre-excited AF is potentially harmful because these drugs accelerate the ventricular rate. III: Harm B
- 23. Pre-excitation Activationof part of the ventricle by an anomalous connection before it is depolarized by the normal atrioventricular (AV) conducting system.
- 24. Louis Wolff(1898-1972) John Parkinson (1885-1976) Paul Dudley White (1886-1973) On April 2,1928, a 35-year-old male patient suffering from racing heart for 10 years came to Dr. White’s office. His physical exam and heart X-ray were normal. White turned the patient over to his assistant Louis Wolff and an ECG was recorded.
- 25. White solicitedthe opinions of other cardiologists on a previously planned trip to Europe. At that time, London and Vienna were top centers for ECG, but Thomas Lewis (White’s teacher in ECG) and Scherf were initially disinterested in the publication of White's unusual Endings. It was only John Parkinson a pupil of Lewis who expressed interest in publication, since he had found similar ECG strips among his own patient records. White and Parkinson coauthored an article in 1930 on the WPW syndrome based on their finding with 11 patients. L. Wolff, J. Parkinson, P. D. White: Bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. American Heart Journal, St. Louis, 1930, 5: 685.
- 26. 1.PR interval <0.12 sec. 2.Abnormally wide QRS ≥ 0.11 sec. 3.Presence of an initial slurring of the QRS (delta wave). 4.Secondary ST-T changes.
- 27. Case 3 77years old lady with Chronic Palpitations and DM HTN CHF. Came with SOB and Palpitations.
- 31. Case 4 60years old lady with chronic Palpitations and previous valve repair Surgery. Admitted for Malena work up
- 35. Non-vitamin K-dependent Anticoagulants/DOACs/NOACs Noninferioralternatives 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
- 36. When should cliniciansconsider 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 Watchman devise
- 39. How should cliniciansmonitor 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
- 40. Conclusion Goals: reducesymptom frequency and severity, prevent stroke, prevent tachycardia-related cardiomyopathy CHA2DS2-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
- 41. Dronedarone iscontraindicated for permanent atrial fibrillation CHA2DS2-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 and others. 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
- 42. Jeanne E. PooleMD, George Johnson BSEE, Kristi H. Monahan RN, Hoss Rostami BSMSE, Adam Silverstein MS, Hussein Al-Khalidi PhD, Mauri Wilson RN, Yves Rosenberg MD, MPH, Tristram D. Bahnson MD, Richard A. Robb PhD, Daniel B. Mark MD, MPH, Kerry L. Lee PhD, Douglas L. Packer MD for the CABANA Investigators and ECG Rhythm Core Lab
- 43. Background CABANA randomized2204 symptomatic patients with paroxysmal or persistent atrial fibrillation (AF) 1:1 to percutaneous left atrial catheter ablation versus medical therapy Patients were > 65 years or < 65 years with > 1 risk factor for stroke Eligible for ablation and ≥2 rhythm or rate control drugs Primary endpoint - Composite of death, disabling stroke, serious bleeding, or cardiac arrest After a median follow up of 48.5 months, there was a non- significant 14% reduction with ablation as assessed by Intention-to-Treat (ITT) .(HR 0.86; 95% CI 0.65-1.15; p=0.30) Packer D et al HRS LBT 2
- 44. Background Secondary endpoint- All cause mortality: A non-significant 15% reduction with ablation was observed (ITT) .(HR 0.85; 95% CI 0.60-1.21; p=0.377) Analyses by treatment received and per protocol showed significant benefits of ablation for both the primary endpoint and for mortality Packer D et al HRS LBT 2
- 45. Selected Baseline Characteristics SelectedBaseline Characteristics Ablation n = 1108 Drug Therapy n = 1096 Age - Median (Q1, Q3) 68 (62, 72) 67 (62, 72) Female 37% 37% NYHA Class II/III 34% 37% History of Stroke or TIA 11% 9% CHA2DS2VASc -- Median (Q1, Q3) 3.0 (2.0, 4.0) 3.0 (2.0, 4.0) Yrs from onset AF - Median (Q1, Q3) 1.1 (0.3, 4.1) 1.1 (0.3, 3.7) Type of AF at enrollment Paroxysmal 42% 43% Persistent 47% 47% Longstanding Persistent 10% 9%
- 46. Conclusions • Catheter ablationwas associated with a significant relative risk reduction (~50%) in recurrence of atrial arrhythmias • Holter-determined AF burden was significantly lower in patients randomized to catheter ablation compared to drug-therapy across 5 years of follow-up AF was the dominant first recurrent rhythm after the 90-day blanking period No treatment difference was observed in recurrent AFL / AT
- 47. Thanks alot