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Atrial Fibrillation

Atrial Fibrillation. Andreas Stein Robert Smith, M.D. August 11, 2003. Definition.

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Atrial Fibrillation

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  1. Atrial Fibrillation Andreas Stein Robert Smith, M.D. August 11, 2003

  2. Definition Atrial fibrillation/flutter is a disorder of heart rhythm (arrhythmia) usually with rapid heart rate, in which the upper heart chambers (atria) are stimulated to contract in a very disorganized and abnormal manner.

  3. Prevalence • Overall prevalence 1% • Increases with age • Higher in men than in women

  4. Classification • Paroxysmal AF: less than 7 days • Persistent AF: longer than 7 days • Permanent AF: longer than 1 year • Lone AF: no structural heart disease

  5. Etiology • AF with Heart disease complicated by the following is most common (~80%): • Atrial enlargement • Elevation of atrial pressure • Infiltration or inflammation of atria • Lone AF (~20%): • Electrophysiologic properties

  6. Etiology (cont) Common diseases underlying AF: • Hypertension • Coronary Heart disease / MI • Rheumatic heart disease • Dilated cardiomyopathy • Hypertrophic cardiomyopathy • Congenital heart disease • Hyperthyroidism • Inflammation

  7. EvaluationofAF History and Physical Examination: • Define symptoms associated with AF • Clinical type or “pattern” (Classification) • Onset or date of discovery • Frequency and Duration • Precipitating causes and modes of termination • Response to drug therapy • Presence of heart disease or potentially reversible causes

  8. EvaluationofAF (cont) • Electrocardiogram: • Presence of AF • Left ventricular hypertrophy • Preexcitation • Bundle branch block • Prior MI • Measure important intervals such as: RR, QRS and QT

  9. EvaluationofAF (cont) • Echocardiogram • Transthoracic Echocardiogram: • size and function of atria and ventricles • low sensitivity for thrombi • Transesophageal Echocardiogram: • High sensitivity for atrial thrombi • Need of anticoagulation prior to cardioversion • Assessment for Hyperthyroidism • TSH measurement

  10. General Treatment Issues • Rhythm control: • reversion to normal sinus rhythm • Rate control: • administration of medications to control the ventricular rate in chronic AF • Choosing between rhythm and rate control • Prevention of systemic embolization

  11. Rhythm Control • Synchronized External DC Cardioversion • hemodynamically stable and unstable patients • ~80% overall success rate • Pharmacologic Cardioversion • hemodynamically stable patients • Class IA ; IC ; III anti arrhythmic drugs • ~60% overall success rate Rule out atrial thrombi by TEE or anticoagulation for 3 – 4 week

  12. Drugs for AF <7Days

  13. Drugs for AF >7 Days

  14. Maintenance of NSR • ~20% maintain in NSR without chronic anti-arrhythmic therapy • Class IA, IC, and III drugs: • Flecainide  minimal heart disease • Amiodarone  reduced EF • Sotalol  coronary heart disease • Alternative methods: • ablative procedures • pacing • insertion of an implantable atrial defibrillator

  15. Maintenance of NSR

  16. Rate control in chronic AF Slowing AV nodal conduction: • beta blocker • calcium channel blocker • digoxin

  17. Rhythm Control vs. Rate Control • Embolic events occur with equal frequency in rate control and rhythm control strategies • Almost significant trend toward a lower incidence of the primary end point with rate control

  18. Prevention of Systemic Embolization • Anticoagulation during restoration of NSR • AF > 48 hours 3 to 4 weeks of warfarin prior to and after cardioversion • recommended target INR is 2.5 • Anticoagulation in chronic AF • Aspirin: low risk patients (<65y; no risk factors) • Warfarin: other than low risk patients ~70% reduction of stroke

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