AF Basics for Office Visits Patient Education NEW Patients with Atrial Fibrillation and/or Atrial Flutter

Anatomy of the Heart The heart sits inside your chest. It is made up of 4 chambers 2 upper (atrium) 2 lower (ventricle) If you take a cross-section of the heart you will see that the upper and lower chambers are separated by valves. There can be problems with the plumbing-- which effect the pumping of the heart Or Problems with the electricity—leading to arrhythmias.

Normal sinus rhythm In Sinus Rhythm the electrical impulse originates at the Sinus Node. It activates the upper chambers to contract. When it reaches the AV node it electrically stimulates the lower chambers of the heart to contract. The heart beats as a 1:1 ratio in a coordinated way. 3

Atrial Fibrillation In Atrial Fibrillation (AF) the electrical impulses originate in the pulmonary vein in the left atrium in a chaotic fashion. These impulses can fire at a rate between 300-500 bmp. The upper chambers quiver. Blood can pool in the heart and cause blood clots. The AV node blocks most impulses to the lower chambers. Consequently, the heart beat is irregular 4

Difference in EKG Strips Normal Sinus Rhythm Atrial Fibrillation

Predisposing Conditions % Proportion of patients 60 57 50 40 29 30 23 20 20 16 16 11 AF is more likely to occur in the setting of underlying structural heart disease or as the initiation or conduction of electrical impulses may thereby be destabilized. Predisposing cardiovascular conditions exist in over 90% of patients with AF. The most common conditions associated with development of AF are hypertension or high blood pressure (HBP), congestive heart failure (CHF) and coronary artery disease (CAD). Other predisposing conditions observed in AF patients include arthritis, cardiomyopathy, peripheral vascular disease (PVD), depression, anxiety, diabetes and gastrointestinal (GI) disorders (Market Certitude 2002). Population-based studies have shown that less than 12% of all AF cases are lone AF, i.e. no history of cardiopulmonary disease or predisposing conditions (Fuster et al 2001). 8 8 10 7 Hypertension CAD Hyper thyroidism Angina PVD CHF CMP Depression / Anxiety Diabetes Idiopathic Market Certitude, LLC Atrial Fibrillation Patient Record Study July 2002

Stages of AF Paroxysmal: Persistent atrial fibrillation: Episodes start and stop on their own Usually last 7 days or less Usually initiated by rapid electrical firing from the pulmonary veins. Persistent atrial fibrillation: Episodes last longer than 7 days Requires medications and/or electrical cardioversion to achieve normal sinus rhythm Electrical impulses can orginate in the pulmonary veins and areas in the left atrium Permanent atrial fibrillation: No longer respondent to medications and cardioversions

Goals of Treatment Stroke Prevention Symptom Management

Stroke Prevention Anticoagulation medication Aspirin Warfarin (Coumadin) Dabigatran (Pradaxa) Non-pharmacologically treatment Watchman device (Left Atrial Appendage excusion device)

Calculating Stroke Risk CHADS2 C ongestive heart failure 1 H ypertension 1 A ge ≥ 75 years 1 D iabetes 1 S troke/ TIA 2 CHADSVAS C ongestive heart failure/LV dysfunction 1 H ypertension 1 A ge ≥ 75 years 2 D iabetes 1 S troke/TIA/TE 2 V ascular disease [prior MI, PAD, or aortic plaque] 1 A ge 65-74 years 1 S ex category (female) 1 Guidelines 0- No anticoagulation needed 1- Anticoagulation up to discretion of patient and physician 2- Anticoagulation required The CHADSVAS score is an enhancement of the CHADS2 score to help identify traditionally the “lower risk patients” to ensure that we decrease their stroke risk with the proper anticoagulation.

Asymptomatic or Symptomatic Atrial Fibrillation Diagnosed with Atrial Fibrillation Asymptomatic AF No change in Functional Status or Quality of Life Symptomatic AF Palpitations Fatigue Exercise Intolerance Shortness of breath Heart Failure Symptoms Vague Symptoms Patient diagnosed with atrial fibrillation: Asymptomatic patients – no change in functional status or quality of life Some patient are vague with regards to symptoms Offer DC cardioversion for asymptomatic patient and also to determine whether or not patient has symptoms associated with atrial fibrillation. Symptomatic patient – may have palpitations, but not always. Patient may experience symptoms of fatigue, SOB, exercise intolerance or heart failure Rhythm Control strategy – AADs and Cardioversion DC cardioversion Rhythm Control Rate Control versus Rhythm Control

Rate versus Rhythm Rate Control Beta Blockers Metoprolol Atenolol Calcium Channel Blockers Diltiazem Verapamil Digoxin Rhythm Control Sodium Channel Blockers Flecainide Propafanone Potassium Channel Blockers Sotalol Dofetilide Multiple Ion Channel Blocker Amiodarone There are two approaches to treating patient atrial fibrillation: Rate control – allows atrial fibrillation to persist in patient who are asymptomatic. Rhythm control- attempting to restore and maintain sinus rhythm in symptomatic patient. Symptomatic patients – may not always have palpitaitons, they may have Exercise intolerance, heart failure symptoms AFFIRM and RACE Studies – Clinical Implications: Survival: Rhythm control offers no survival advantage over Rate control Recommend anticoagulation therapy for both approaches AFFIRM Investig., New Engl J Med., 2002 Vol. 347, No. 23 12

Important considerations for patient selection for PVI Is there an indication for a PVI? Symptomatic Failed antiarrhythmics Paroxysmal or persistent Paroxysmal AF has a higher success rate than persistent AF. Important in choosing ablation method (cryo vs RFA) Physical limitations Works best when left atrium is not excessively enlarged (greater than 55 mm). Less effective and more challenging in patients with structural heart disease

PVI Typically done under general anesthesia. 4-8 hours in duration 24 hour admission

Atrial Fibrillation: Catheter ablation or PVI Pulmonary vein isolation (PVI) is done under general anesthesia. 6-8 hours Catheters are inserted into your groins and advanced up inside the heart. The catheter is advanced to the left atrium. The target area is the pulmonary veins. The Physician burns in a dot-by-dot fashion to isolate the pulmonary veins.

Integrated MRI and Mapping to Guide AF Ablation Picture of the dot-by-dot approach. #155

Risk Associated with Ablation Limited Complications Perforation of the Heart (Cardiac Tamponade) Guided imagery throughout case Pulmonary Vein Stenosis Monitor by CT scan or MRI after case Stroke/TIA Continue anticoagulation throughout procedure Atrial-Esophageal Fistula Monitor temperature throughout procedure in esophagus MGH Statistics Cardiac Tamponade 1.5% Pulm Vein Stenosis 0.1% Stroke TIA 0.6% Comparative to worldwide survey investigating the methods, efficacy, and safety of catheter ablation of atrial fibrillation 1995-2002 Cappato et.al, Circulation, March 2005