Atrial fibrillation J Heinsimer MD

Atrial fibrillation (“A Fib”) What is it ? Why do we care if I have A Fib? How common is A Fib ? What causes A Fib? How do we get rid of Afib? If we cannot get rid of afib, how do we control it?

Atrial fibrillation (“A Fib”) What is it ? Why do we care if I have A Fib? How common is A Fib ? What causes A Fib? How do we get rid of Afib? IF we cannot get rid of afib, how do we control it?

atrial fibrillation (top chambers- the atria - going 400-600 beats/ minute) – too fast to pump blood

Atrial fibrillation vs atrial flutter

Atrial fibrillation (“A Fib”) What is it ? Why do we care if I have A Fib? How common is A Fib ? What causes A Fib? How do we get rid of Afib? If we cannot get rid of afib, how do we control it?

Atrial fibrillation (“A Fib”) What is it ? Why do we care if I have A Fib? How common is A Fib ? What causes A Fib? How do we get rid of Afib? IF we cannot get rid of afib, how do we control it?

Atrial fibrillation (“A Fib”) What is it ? Why do we care if I have A Fib? How common is A Fib ? What causes A Fib? How do we get rid of Afib? If we cannot get rid of afib, how doe we control it?

Causes of Atrial fibrillation High blood pressure (probably 50% of afib) Caffeine - coffee, tea, energy drinks, cocoa Excess Alcohol Aging Nicotine Fluid around the heart (“pericarditis”) Low potassium, low oxygen, overactive thyroid Any disease damaging heart muscle including heart attack (“Myocardial infarction”)

Drug-induced heart rhythm Bradycardia (too slow), tachycardia (too fast – over 100)

Dietary Supplements Causing Palpitations Chocolate Ephedra/Diet pills Ginseng Bitter Orange Valerian Hawthorn

Atrial fibrillation (“A Fib”) What is it ? Why do we care if I have A Fib? How common is A Fib ? What causes A Fib? How do we get rid of Afib? If we cannot get rid of afib, how do we control it?

Four ways to deal with A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

Four ways to deal with A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

Fixing the underlying cause of A Fib This should be the cornerstone of all treatment – involves measuring labs for potassium, thyroid and doing an echocardiogram (ultrasound test to look for fluid around heart, look at valves, look at heart chambers and heart pumping) Stop all caffeine, cut down on alcohol to less than 2 drinks/day, get blood pressure below 130/85 with meds measuring bp at home, stop smoking, care with drugs that may cause A Fib such as some inhalers for lung disease

Four ways to deal with A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

Shock “cardioversion” for new onset atrial fibrillation (usually done after at least 3 weeks of anticoagulation unless A Fib is known to be present for <48 Hours) Patient is put to sleep for a few seconds with IV meds so he does not feel shock

Four ways to deal with A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

The AV node (3 in diagram below) determines how many of the 400-600 beats from the fibrillating atrium get to the ventricle

Four ways to deal with A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

Atrial Fibrillation – top chamber (atrium) at 400-600 beats/minute (too fast to pump blood)

A Fib ablation done in the cath lab - takes 2 -10 hours

Catheter ablation with catheter going from leg to right atrium then to left atrium to sites in left atrium around pulmonary veins

Catheter ablation with catheter going from leg to right atrium then to left atrium to sites in left atrium around pulmonary veins Pulmonary vein in L atrium

Risks of A Fib ablation Usual risks with catheterization: bleeding, injury to blood vessel, dye allergy, death (all <1%) Long procedure (2-10 hours) 70% success rate with initial procedure (sometimes drugs or redo are needed) Usually only done in selected patients who cannot tolerate the A Fib without severe symptoms

How do we deal with my A Fib Fix underlying cause ! If we can find a cause (lab tests, echo) we will fix it – fix bp, caffeine, alcohol Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

How do we deal with my A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular (if 1st episode of A Fib, fix underlying cause and if heart rhythm still does not convert to normal, then consider medications and/or shock) Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

How do we deal with my A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body (if recurrent episodes of afib and over 60 years old) Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib

How do we deal with my A Fib Fix underlying cause ! Use drugs or shock to convert afib back to normal sinus rhythm and hope that the rhythm stays regular Allow the patient to stay in atrial fibrillation and give drugs to control the ventricular rate and prevent stroke or clot from going to body Surgical or catheter techniques to interrupt abnormal pathways to “ablate” A Fib (if no underlying cause and recurrent episodes of A Fib associated with severe symptoms or patient <60)

Why not get everyone back in normal sinus rhythm with drugs or ablation ? Drugs all have toxicity and the potential to make things worse Procedures such as ablation are difficult, do not work in 1/3 of the time, the A Fib returns at a rate of 3-5% per year even after initially successful ablation The AFFIRM study was a large study in patients over 60 that showed that long term treatment with blood thinners together with drugs to control the ventricular rate (“rate control strategy”) was as good if not better than a “Rhythm control strategy” designed to keep in normal rhythm (see next 2 slides)

Conclusions - Atrial Fibrillation Fix underlying cause ! Use warfarin (Coumadin) to control clots (newer drugs are emerging since Coumadin is a dangerous drug). Aspirin (instead of Coumadin) may be acceptable for patients at low risk for stroke. Learn everything you can about Coumadin if on it. Control the ventricular rate if in atrial fibrillation Control rhythm or do ablation if severe symptoms or age under 60