Atrial

Atrial Fibrillation
Fibrillation
(AF)
(AF)
By Stephanie Chieng
 Introduction
• AF is a cardiac arrhythmia (abnormal heart
rhythm) that involves the two upper chambers
(atria) of the heart.
• It is a loss of atrial contribution to ventricular
filling (inefficient movement of blood to
ventricles due to incomplete filling of atria)
 Introduction (cont’)
• In AF, the normal electrical impulses (by the
SA node) are overwhelmed by disorganized
electrical impulses that originated in the atria
and pulmonary veins, leading to conduction of
irregular impulses to the ventricles that
generate the heartbeat.
• The result is an irregular heartbeat which may
occur in episodes lasting from minutes to
weeks, or it could occur all the time for years.
 Signs & Symptoms
• Often asymptomatic, and is not in itself
generally life-threatening
• Common Sx: chest palpitations, dyspnoea on
exertion (DOE)
• Light headedness, dizziness, reduced exercise
tolerance (due to reduced CO and inadequate
cerebral blood flow)
• Reduced CO results in signs of HF ( JVP,
ankle oedema, fluid in the lungs)
 Causes
• Most commonly associated with CVD, IHD,
CHF, CVA
• Valve diseases, atrial septal defect
• HTN, COAD, pulmonary embolism,
hyperthyroidism
• Excessive alcohol intake; an alchoholic
cardiotoxicity caused by an episode of binge
drinking
 Types of AF
• The American College of Cardiology (ACC), American Heart
Association (AHA), and the European Society of Cardiology
(ESC) recommend in their guidelines the following
classification system based on simplicity and clinical relevance

AF Category Defining Characteristics

1st detected Only 1 diagnosed episode

Praroxysmal recurrent episodes that self-terminate in less

than 7 days
Persistent recurrent episodes that last more than 7 days

Permanent An on-going long term episode

 Diagnosis
• Clinical history, physical examination
• Evaluation of ECG- check rhythm
• Echocardiogram; trans-thoracic or trans-
oesophageal (more invasive,but not as much
tissue top penetrate to achieve visualisation)
 Types of Treatments
(i) Rhythm control i.e reversion to normal sinus
rhythm (NSR)
(ii) Rate control i.e administration of
medications to control ventricular rate,
followed by maintenance of NSR and
(iii) Prevention of systemic emolization with
anticoagulant (or antiplatelet in selected
patients)
• Paroxysmal- rate control alone maybe
appropriate for brief or minimally symptomatic
recurrences
• Persistent/permanent- control of ventricular
rate is commonly the initial strategy.
• Principle: slow HR, then restore NSR
• Reduce risk of stroke
• Tx any underlying disorder that’s causing or
raising the risk of AF—for example,
hyperthyroidism.
• Initial Tx is up to whether major goal of
therapy is control of ventricular rate, or
whether attempts are to be made to obtain
and maintain sinus rhythm.
• The AFFIRM trial ('rate control' vs 'rhythm
control') showed no statistically significant
difference in mortality or in quality of life
between the two options.
Rhythm control
• Rhythm control allows the atria and
ventricles to work together again to
efficiently pump blood to the body.
• Electrical cardioversion (CD): a jolt of
electricity delivered to the heart to
"convert" the rhythm from AF back to a
normal heart rhythm.
• Medicines (pharmacological CD) used to
control a person’s heart rhythm include
amiodarone,flecainide, sotalol etc;
occasionally older medicines such as quinidine,
procainamide, and disopyramide.
• Electrical CD is preferred when patient is
haemodynamically unstable.
• Patients with left atrail size of <4.5-5c, AF of
recent onset, little or not HF, and an
underlying reversible cause such as
hyperthyroidism, MI have higher chance of
successful cardioversion.
• Chronic AF is difficult to manage, so may have
to resort to other approaches to control
rhythm: implantable devices or AV node
ablation.
 Pharmacological CD
• Amiodarone: Initially 200mg TDS for 1wk,
reduce to 200mg BD for a further wk.
Maintenance: 200mg/day or lowest effective
dose.
• Flecainide: 200-300mg as single dose
• Quinidine: 0.75-1.5g in divided dose over 6-12hrs
• Propafenone: 450-600mg as single dose
 Maintaining sinus rhythm
• The main indication for antiarrhythmic drug
therapy to maintain sinus rhythm after CD are
the persistent Sx despite rate control strategy
(palpitations,weakness,dizziness,HF) & patient
preference for rhythm control.
• Satolol: Initially, 80 mg daily as a single or in 2
divided doses, increased gradually every 2-3
days. Maintenance: 160-320mg daily in 2 divided
doses. Max: 640 mg daily.
• Monitor for excessive QT prolongation; cease if
QT increases by >20% from baseline; use low
doses or not at all in patients with impaired
renal function
• Flecainide: 50-100mg BD. Max: 400mg/day
• Disopyramide: 400-750mg in 4 divided doses.
(as conventional capsules every 6hr; as
extended-release capsules every 12hr)
• Amiodarone is also effective in sinus rhythm
control. However, caution need to be
exercised due to its long term adverse
effects profile.
Rate Control
• Rate control in AF usually achieved by slowing
AV conduction with IV/oral beta-blockers,
diltiazem,verapamil or in patients with HF,
digoxin is used as single agent or in combination.
• Aim for ventricular rate <80b/min at rest &
180b/min on exercise. Some patients have
controlled ventricular rate & hence do not
require specific Tx.
• DO NOT combine verapamil with beta-blockers
as risk of bradycardia & reduced CO .
Drugs for HR control
• Metoprolol 25 to 100 mg orally, BD
• Propanolol 30-160mg/day in divided doses
• Diltiazem 40-120 mg daily TDS
• Verapamil 40-120 mg daily TDS
• Digoxin loading: 250-500mcg q4-6hrs, to a
max of 1.5mg. Maintenance: 125-250mcg OD
(rarely up to 500mcg daily)
• Halve the digoxin dosage in elderly and renal
impairment patient. Monitor serum digoxin
level to prevent toxicity.
• When taking digoxin, best to obtain potassium
level of 4-5.5mmol/l.
• If use with amiodarone, halve the digoxin dose
due to risk of toxicity.
• Signs of toxicity: PR interval prolongation,
xanthopsia(yellow vision), delirium
• Digoxin alone is insufficiet in slowing rapid
ventricular rate associate with increased
sympathetic tone (exercise, hyperthyroidism,
fever). Consider alternative or combining with
beta-blockers, verapamil or diltiazem.
 Anticoagulants
• Patients with AF usually have a significantly
increased risk of stroke (up to 7x that of the
general population).
• Hence, preventing the formation of blood clots
is an important part of treating AF .
• Warfarin is the most effective medicine in
prevention of stroke.
• It reduces the risk of stroke by 60%, while the
reduction with aspirin is about 20%.
• Aspirin is used when warfarin is C/I.
3 risk categories for thromboembolism:
• High risk patient: patients with a previous
thromboembolic event thought to be
secondary to their fibrillation and patients
with longstanding mitral valve disease. Should
all be on long-term warfarin unless there are
very strong C/I aspirin 75-300mg/day
• Intermediate risk: The presence of a history
of hypertension, age >65yrs, LV dysfunction or
history of HF. Based on GP’s clinical judgment
on whether or not to introduce warfarin or
aspirin.
• Low risk: patient <65yrs, with an
echocardiographically normal heart and no
history of HTN or any of the other risk
factors for thromboembolism. Probably do
not need treatment with warfarin.
• Recent results of the Stroke Prevention in
Atrial Fibrillation III (SPAF III) trial
demonstrated a 75 percent reduction in the
risk of stroke for people taking adjusted
dose of warfarin in AF.
 INR
• Recommended warfarin dose is 5mg/day.
• Target INR range for warfarin is 2 to 3
• Except perhaps in patients who have already
suffered thromboembolic events with an INR in
this range, a target of 2.5 to 3.5 may seems
reasonable.
• In patients age >75yrs who are at risk of major
bleeding, a target INR of 1.8-2.5 may be a
reasonable compromise.
Counselling on warfarin
• Ensure patient understand the INR values.
• Diet issue- a normal constant amount of
vitamin K intake (green leafty veges i.e
spinach, green tea, cabbage & animal liver etc)
• Do not take any OTC products/supplements
before consulting with your doctor.
• Purple toe syndrome- bilateral, painful purple
lesions on toes. Stop medication & seek
medical advise immediately.
 References
• Australian Medical Handbook.2006
• Sarawak Handbook of Medical Emergencies. 2nd
edition.2005.
• Adjusted-dose warfarin versus low-intensity, fixed-
dose warfarin plus aspirin for high-risk patients with
atrial fibrillation: Stroke Prevention in Atrial
Fibrillation III randomized clinical trial." The Lancet,
September 7, 1996, 348, 633-638.
• Therapeutic Guidelines. 2003. Australia
• www.mims.com.my