Palpitations & Atrial Fibrillation Dr Mehul B Dhinoja, Consultant Cardiologist & Electrophysiologist BMI The London Independent Hospital

v Palpitations Situations Beginning During Ending Duration Frequency Other symptoms Family history

v Gold standard for diagnosis

v Which recording method? 24 hour Holter 48 hour Holter 72 hour Holter 7 day Holter Event recorder Loop recorder 12 lead ECG Symptom frequency Information required

v Other investigations Thyroid function Cardiac MRI Cardiac CT Cardiac catheter Cardiac biopsy Provocation testing Echocardiogram Genetic testing

v Example

v Consequences of AF

v Treatment goals in AF European Society of Cardiology, 2010

v Risk stratification European Society of Cardiology, 2010 ≥ 2

v Stroke prevention Anticoagulation Warfarin Novel Oral Anticoagulants Unsuitable Left Atrial Appendage Occlusion CHADS-VASC ≥2 Dabigatran Rivaroxaban Apixaban

v Rate control LV function Tachy-Brady Syndrome Biventricular Pacemaker AV nodal Ablation Good Impaired Beta Blockers Calcium Blockers ±Digoxin Beta Blockers ±Digoxin Tachy-Brady Syndrome HF Drugs Single Chamber Pacemaker ICD Indication? Review medications

v Rhythm control Impaired LV function ± Coronary disease Recurrent symptomatic AF AF ablation No Yes Flecainide Sotalol (Dronedarone) (Sotalol) HF Drugs Disopyramide/Propafenone (Dronedarone) (Amiodarone) DC cardioversion

v Underlying conditions Atrial fibrillation Heart failure Cardiomyopathies Inherited arrhythmias Vascular Disease Obstructive Sleep Apnoea Diabetes Mellitus Hypertension Thyrotoxicosis None

v Prognosis after AF ablation Hunter et al, 2011

v Prognosis after AF ablation Hunter et al, 2011