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Atrial Fibrillation. Rate or rhythm control? Who should be anticoagulated? Other treatment strategies. Classification:. Aetiology. LONE AF. VS. ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC. Classification:. Aetiology. Timing. LONE AF. FIRST EPISODE. VS. OR.
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Atrial Fibrillation • Rate or rhythm control? • Who should be anticoagulated? • Other treatment strategies
Classification: Aetiology LONE AF VS ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC
Classification: Aetiology Timing LONE AF FIRST EPISODE VS OR ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC RECURRENT PAROXYSMAL PERSISTENT PERMANENT Circulation 2001;104:2118 –2150
Prevalence of AF: JAMA. 2001;285:2370-2375
Burden of AF: Palpitations AF 5% > 65 Syncope/Presyncope Fatigue
Burden of AF: Palpitations AF 5% > 65 Syncope/Presyncope Fatigue DyspnoeaOedema Stroke Heart Failure
Prognosis of AF: Circulation1998;98:946-952
Principles of management: • RESTORATION & MAINTENACE OF SINUS RHYTHM‘Rhythm control’ • CONTROL OF VENTRICULAR RATE‘Rate control’ • REDUCE THROMBOEMBOLIC RISK
Restoration of SR: RESTORATION OF SINUS RHYTHM NB 60% REVERT SPONTANEOUSLY IN <24 HOURS ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK • PHARMACOLOGICAL • 1) FLECAINIDE: • 2) PROPAFENONE • 3) AMIODARONE • 4) DOFETILIDE
Restoration of SR: ANTICOAGULATION? RESTORATION OF SINUS RHYTHM HOW LONG IN AF? NB 60% REVERT SPONTANEOUSLY IN <24 HOURS ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK • PHARMACOLOGICAL • 1) FLECAINIDE: • 2) PROPAFENONE • 3) AMIODARONE • 4) DOFETILIDE <48 HOURS NO HEPARIN 3 WEEKS WARFARIN POST SHOCK >48 HOURS 3 WEEKS WARFARIN PRE & POST SHOCK or TOE GUIDED SHOCK + 3 WEEKS WARFARIN POST SHOCK
Maintenance of SR (=prevention of AF recurrences): 1) DRUG TREATMENT:
Maintenance of SR (=prevention of AF recurrences): • 2) OTHER TREATMENTS: • Pacing • Atrial Defibrillators • Cardiac Surgery • Catheter radiofrequency ablation
Rate control: VENTRICULAR RATE CONTROL PHARMACOLOGICAL 1) DIGOXIN 2) BLOCKER 3) CA CHANNEL BLOCKER 4) AMIODARONE • ABLATION • RADIOFREQUENCY • ABLATION OF • ATRIOVENTRICULAR NODE • + • PACEMAKER
Rate vs rhythm control: Rate (Remain in AF):Rhythm (Restore SR): advantages Good symptom control Good symptom control Simple low risk treatment Normal physiology/cardiac function Better prognosis ?? disadvantages Abnormal cardiac function Complex higher risk treatment Stroke risk ?? Antiarrhythmic drugs - proarrhythmic Worse prognosis??
Rate vs rhythm control - PIAF: PIAF study Lancet 2000;356;1789-94
Rate vs rhythm control – AFFIRM: n = 4000 age = 70 • Rate: • Digoxin • Blocker • Ca channel blocker • Rhythm: • Amiodarone • Propafenone • Sotalol • +/- DC Cardioversion AFFIRM study - NASPE 2002
Risk of Stroke? • 1 in 6 strokes have AF • 6 x stroke rate if have AF • TYPE OF AF IS NOT A RISK DETERMINANT Optimal INR?