1 / 55

The Internists Approach to Atrial Fibrillation:

The Internists Approach to Atrial Fibrillation:. A Simple Strategy for a Complex Problem Peter Holzberger, MD 12/4/03. Focus . Immediate Treatment Anticoagulation Maintenance Issues. Background. Atrial fibrillation is the most common sustained arrhythmia Affects 2 million Americans

talbot
Télécharger la présentation

The Internists Approach to Atrial Fibrillation:

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Internists Approach to Atrial Fibrillation: A Simple Strategy for a Complex Problem Peter Holzberger, MD 12/4/03

  2. Focus • Immediate Treatment • Anticoagulation • Maintenance Issues

  3. Background • Atrial fibrillation is the most common sustained arrhythmia • Affects 2 million Americans • 6% over the age of 65 experience it • Responsible for 15% strokes • Benjamin E: Epidemiology of Atrial Fibrillation. In Falk RH, Podrida PJ, eds:Atrial Fibrillation: Mechanisms and Management. 2nd Ed, Lippincott-Raven Press, New York 1997, pp.1-22.

  4. Atrial Fibrillation Demographics by Age U.S. populationx 1000 Population with AFx 1000 Population withatrial fibrillation 30,000 20,000 10,000 0 500 400 300 200 100 0 U.S. population <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 >95 Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473. Age, yr

  5. Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis. • 6% PSVT • 6% PVCs • 18% Unspecified 2%VF • 4% Atrial Flutter • 9% SSS • 34% Atrial Fibrillation • 8% Conduction Disease • 10% VT • 3% SCD Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

  6. Symptoms • Inappropriate heart rate response • Tachymyopathy • Irregular rate • Loss of atrial systolic function • Thromboembolism

  7. Guidelines

  8. Immediate Treatment • Cardiovert • Hemodynamic collapse • Control the Rate Assess symptoms

  9. Immediate Treatment • Significant symptoms • Restore NSR +/- Antiarrhthymics • Minimal symptoms • Strongly Consider rate control

  10. Immediate Treatment • History,Physical,Labs • Underlying heart disease,thyroid,alcohol • ECG • LVH, WPW, MI • CX • Pneumonia • Echocardiogram • Blown ticker • ETT/Holter • Rate assessment

  11. Immediate Treatment • Categorize the atrial fibrillation • Follow the flowchart • When faced with the antiarrhythmic option consider getting a referral • almost never needed in the acute decision process • exception: IV Amiodarone

  12. Guidelines: Definitions

  13. Case: 1 • 40 yr old male • Seen in ED with new onset palpitations • Started 2 hrs ago • Otherwise healthy but nervous • ECG: atrial fib 160 • Rx’d with beta blocker: HR 85 • Feels much better

  14. Categorize • 1: Is it Paroxysmal? • 2: Is it Persistent? • 3: Is it Permanent?

  15. What Next? • 1: DC Cardioversion +/- TEE • 2: IV Amiodarone • 3: IV Ibutilide • 4: Come back in 24 hrs and reevaluate

  16. Placebo • Cotter et al,.Eur Heart J Dec 1999; 20(24):1833-42 P=0.0017 Conversion (%)

  17. < 24 hrs duration • Minimally symptomatic with rate control • Observe for another 24 hrs (may be paroxysmal) • Anticoagulate if indicated

  18. < 48hrs but > 24hrs • Cardiovert if NSR is desirable • Most patients with new onset atrial fibrillation regardless of age • Rate control and anticoagulation if appropriate • Hx or recurrent paroxysmal with minimal sx’s usually in the elderly

  19. Case: 2 • 50 yr old female hasn’t felt well for 3 days • Otherwise healthy • ECG atrial fib rate 140 • Rx’d beta blocker: HR 105 • Still feels terrible

  20. What next? • 1: DC Cardioversion +/- TEE • 2: IV Amiodarone • 3: IV Ibutilide • 4: Come back in 24 hrs and reevaluate

  21. Manning WJ. N Engl J Med. 1993;328:750-755. A Left Atrium B Left Atrial Appendage Clot

  22. > 48 hrs • TEE cardioversion followed by anticoagulation if symptom intolerant • Rate control and anticoagulation for 1 month before attempted cardioversion if NSR is desired • Long term rate control and anticoagulation

  23. Guidelines:Newly Discovered AF

  24. Guidelines:Recurrent Paroxysmal

  25. Case: 3 • 83 yr old noted to be in atrial fibrillation on routine office visit - asymptomatic • Otherwise healthy except for HTN • Wonders what all the fuss is about • Evaluation for underlying causes is negative

  26. What next? • 1: If it ain’t broke don’t fix it • 2: Anticoagulate, rate control and cardiovert 1 month later • 3: Anticoagulate and rate control • 4: Rate control

  27. Case: 4 • 38 yr old with atrial fib noted on routine physical asymptomatic • Otherwise healthy • Evaluation unremarkable

  28. What next? • 1: If it ain’t broke don’t fix it • 2: Anticoagulate, rate control and cardiovert 1 month later • 3: Anticoagulate and rate control • 4: Rate control

  29. Guidelines: Recurrent Persistent

  30. Rate Control : A New Paradigm • 5 Randomized trails of Rhythm vs. Rate • PIAF - 252 • PAF2 - 141 • RACE - 522 • STAF - 200 • AFFIRM - 4060 patients • 3.5 yrs

  31. AFFIRM

  32. Stroke • AFFIRM • 77 (5.5%) rate control and 80 (7.1%) rhythm control • 1% per year • Majority associated with no Coumadin or INR <2 • RACE • 14 (5.5%) rate control and 21 (7.9%) rhythm control • 6 strokes after stopping Coumadin (5 in sinus) • 23 with INR <2

  33. Anticoagulation: The Gold Standard • 5 large prospective randomized trials • All comparing warfarin to placebo while utilizing rate control. • All with the same highly significant result • Embolic risk decreases to 1.4% (68% reduction)

  34. Warfarin

  35. Who Gets Warfarin?

  36. Everyone with Atrial Fibrillation Except: “Lone” Atrial Fibrillation Absence of identifiable cardiovascular, pulmonary, or associated systemic disease Approximately 0.8 - 2.0% of patients with atrial fibrillation (Framingham Study)1 In one series of patients undergoing electrical cardioversion, 10% had lone AF.2 1 1Brand FN. JAMA. 1985;254(24):3449-3453.2 Van Gelder IC. Am J Cardiol. 1991;68:41-46.

  37. Predictors of Thromboembolic Risk in Atrial Fibrillation • Previous Stroke or TIA - 2.5 • History of HTN - 1.6 • CHF - 1.4 • Advanced Age >65 yrs (cont. per decade) - 1.4 • DM - 1.7 • CAD - 1.5 Atrial Fibrillation Investigators. Arch Intern Med. 1994;154:1449-1457.

  38. Exception for 325 mg ASA Age <75 yrs No risk factors Normal echo

  39. How to treat the symptomatic • Referral: • Antiarrhthymics • Ablation • AV Junction • Pulmonary Veins • Surgery • MAZE

  40. Maintenance Issues • Rate Control • Annual Holter with mean HR below 100 • Anticoagulation • Monthly INR when stabilized • Antiarrhythmic Rx • Periodic ECG, drug level -if possible, LFT and kidney function

  41. Atrial Fibrillation: Surgery • Hold anticoagulation 4 days prior to surgery • Start back on day of surgery • Exceptions • High risk embolization-bridge with heparin • Embolization within 3 months • Mechanical mitral valve

  42. Case: 5 • 70 yr old male with HTN develops atrial fib post op day 2 following emergency cholycystectomy • Rate is adequately controlled • No acute issues • No prior history of atrial fib

More Related