Atrial Fibrillation Rate or rhythm control? Who should be anticoagulated? Other treatment strategies

Classification: Aetiology LONE AF ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC VS

Classification: FIRST EPISODE PERSISTENTPAROXYSMAL PERMANENT RECURRENT OR TimingAetiology LONE AF ALCOHOL RHEUMATIC HYPERTENSION HYPER THYROIDISM ISCHAEMIC ETC VS Circulation 2001;104:2118 –2150

Prevalence of AF: JAMA. 2001;285:

Mechanism of AF:

Burden of AF: AF 5% > 65 Fatigue Palpitations Syncope/Presyncope

Burden of AF: AF 5% > 65 Heart Failure Fatigue Stroke Palpitations Syncope/Presyncope Dyspnoea Oedema

Prognosis of AF: Circulation 1998;98:

Principles of management: 1.RESTORATION & MAINTENACE OF SINUS RHYTHM ‘Rhythm control’ 2.CONTROL OF VENTRICULAR RATE ‘Rate control’ 3.REDUCE THROMBOEMBOLIC RISK

Restoration of SR: RESTORATION OF SINUS RHYTHM ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK PHARMACOLOGICAL 1) FLECAINIDE: 2) PROPAFENONE 3) AMIODARONE 4) DOFETILIDE NB 60% REVERT SPONTANEOUSLY IN <24 HOURS

Restoration of SR: RESTORATION OF SINUS RHYTHM ELECTRICAL 1) EXT DC SHOCK 2) INTERNAL SHOCK PHARMACOLOGICAL 1) FLECAINIDE: 2) PROPAFENONE 3) AMIODARONE 4) DOFETILIDE NB 60% REVERT SPONTANEOUSLY IN <24 HOURS ANTICOAGULATION? HOW LONG IN AF? <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): advantagesGood symptom control Simple low risk treatmentNormal physiology/cardiac function Better prognosis ?? disadvantages Abnormal cardiac functionComplex higher risk treatment Stroke risk ??Antiarrhythmic drugs - proarrhythmic Worse prognosis??

Rate vs rhythm control - PIAF: PIAF study Lancet 2000;356;

Rate vs rhythm control – AFFIRM: AFFIRM study - NASPE 2002 n = 4000  age = 70 Rate: Digoxin  Blocker Ca channel blocker Rhythm: Amiodarone Propafenone Sotalol +/- DC Cardioversion

Risk of Stroke? Optimal INR? 1 in 6 strokes have AF 6 x stroke rate if have AF TYPE OF AF IS NOT A RISK DETERMINANT

Who should be anticoagulated?