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ATRIAL FIBRILATION

ATRIAL FIBRILATION. Raj Chahal. First Steps. CONFIRM DIAGNOSIS (ECG) IMMEDIATE RESUSCITAION AIRWAY BREATHING CIRCULATION HAEMODYNAMIC PROFILE HEART RATE BLOOD PRESSURE. TYPES. PERMANENT PERSISTENT PAROXYSMAL. AF WITH FAST VENTRICULAR RATE AF WITH APPROPRIATE RATE. UNSTABLE.

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ATRIAL FIBRILATION

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  1. ATRIAL FIBRILATION Raj Chahal

  2. First Steps • CONFIRM DIAGNOSIS (ECG) • IMMEDIATE RESUSCITAION • AIRWAY • BREATHING • CIRCULATION • HAEMODYNAMIC PROFILE • HEART RATE • BLOOD PRESSURE

  3. TYPES • PERMANENT • PERSISTENT • PAROXYSMAL

  4. AF WITH FAST VENTRICULAR RATE • AF WITH APPROPRIATE RATE

  5. UNSTABLE • HYPOTENSIVE • CHEST PAINS • Consider reversible causes • Haemorrhage • PE • Call senior help and consider emergency DCCV under sedation.

  6. STABLE • History and Examination • Confirm diagnosis • Consider exacerbating causes • Stroke risk assessment • Rate or Rhythm control

  7. Exacerbating Causes • Infection • Hyperthyroidism • Alcohol • Caffeine • Surgery • Ischaemia

  8. Stroke Risk Assessment • CHADS2 SCORE • Cardiac Failure • Hypertension • Age over 75 • Diabetes • Stroke/TIA (2) 0 - Aspirin alone 1 - Aspirin or Warfarin ≥2 - Warfarin Consider patient choice and logistics/safety of warfarin

  9. Rate or Rhythm Control

  10. Try rhythm-control first for patientswith persistent AF: • who are symptomatic • who are younger • presenting for the first time with lone AF • secondary to a treated or corrected precipitant • with congestive heart failure. • CARDIOVERSION FROM AF • MAINTENANCE OF SR

  11. Try rate-control first for patients with persistent AF: • over 65 • with coronary artery disease • with contraindications to antiarrhythmic drugs • unsuitable for cardioversion

  12. Practicalities • On initial assessment on finding AF before deciding on aspirin or warfarin • GIVE THERAPEUTIC DOSE LMWH DALTPARIN (FRAGMIN) unless contraindicated

  13. Rhythm Control - cardioversion • Consider onset • <48 hours • >48 hours • If less than 48 hours then less chance of thrombus formation. • IV amiodorone 300mg over 1 hour • IV amiodorone 900-1200mg over 23 hours • DCCV under sedation

  14. If greater than 48 hours • Warfarin for 3-6 weeks • Request echo • Request DCCV • Continue warfarin for 4 weeks post • In high risk of recurrence, continue warfarin

  15. RHYTHM CONTROL – maintenance • When back in SR consider medication to maintain in SR. • Oral amiodarone (remember counselling & monitoring) • 200mg tds 1/52; 200mg bd 1/52; 200mg od thereafter • If no structural heart disease: • Oral flecainide • Oral sotalol • Oral propafenone

  16. RATE CONTROL • In permanent AF • Left atrial enlargement • AF over year • Recurrent AF • Use beta-blocker (bisoprolol) or rate limiting calcium channel blocker (diltiazem) • Further rate control can be gained with digoxin and amiodarone

  17. FOLLOW UP • In those with rhythm control check with 24 hour ECG as OP after 4/52

  18. Questions?

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