Update in Atrial Fibrillation พญ. กนกศรี อัศวสันติ อายุรแพทย์โรคหัวใจและหลอด เลือด กลุ่มงานอายุรกรรม โรงพยาบาลเพชรบูรณ์

 1-2% of general population  Average age 75 – 85 years  5 fold risk of stroke  3 fold risk of CHF  Higher mortality

Causes of AF Cardiovascular  VHD - rheumatic MS - prosthetic heart valve - MV repair  Myocardial disease  Coronary artery disease ( CAD )  Congenital heart disease ( e.g. ASD )  HT Non cardiovascular  Aging  DM  Obesity, sleep apnea  Hyperthyroid / Hypothyroid  COPD  Sepsis  CKD  Post surgery

Mechanisms of AF

Clinical presentations of AF  Asymptomatic  Dyspnea on exertion, exercise intolerant  Palpitation  Syncope  Heart failure  Systemic thromboembolism ( stroke, acute arterial occlusion )

Physical examination  irregulary irregular pulse rate  signs of associated diseases

Screening for AF Pulse palpation in patient age > 65 If irregular  ECG

Investigations in AF  Blood chemistry ( e.g. CBC, serum Cr )  TFT  CXR  Echocardiogram  Holter monitoring

Definitions of AF: A Simplified Scheme TermDefinition Paroxysmal AF  AF that terminates spontaneously or with intervention within 7 d of onset.  Episodes may recur with variable frequency. Persistent AF  Continuous AF that is sustained >7 d. Long-standing persistent AF  Continuous AF >12 mo in duration. Permanent AF  The term “permanent AF” is used when the patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm.  Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of AF.  Acceptance of AF may change as symptoms, efficacy of therapeutic interventions, and patient and clinician preferences evolve. Nonvalvular AF  AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.

Valvular AF 1.Rheumatic mitral stenosis 2.Prosthetic heart valve 3. Mitral valve repair Nonvalvular AF Lone AF 1.Nonvalvular AF 2.Age < 65 year

Management of AF  Rhythm control : restoration and maintenance of sinus rhythm  Rate control : ventricular rate  Clot control : prevention of thromboembolic event

Rhythm control ( recent-onset AF < 48 hrs )  Medical cardioversion  Electrical cardioversion  Pill in pocket : paroxysmal AF

Strategies for Rhythm Control in Patients with Paroxysmal* and persistent AF†

Direct current cardioversion  Informed- consent : indication and complication  Adequate sedation  AP electrode placement more effective than anterolateral placement  Biphasic waveform : J  If PPM or ICD : electrode paddle at least 8 cm from generator

Factor predispose to AF recurrence  Age  AF duration before cardioversion  Number of previous recurrence  Increase LA size  Reduced LV function  Presence of CAD or pulmonary or mitral valve disease  Atrial ectopic beat with long – short sequence  Faster HR  Variation in atrial contraction

Rhythm control AF > 48 hrs

Rate control  Stable : BB / non dihydrpyridine CCB  Severely compromised : iv Verapamil/ Metoprolol / Digoxin  Severe Depressed LV function : Amiodarone  AF with slow ventricular response : Atropine if symptomatic bradycardia  TPM **** After acute control  follow with long term rate control

Approach to Selecting Drug Therapy for Ventricular Rate Control*

Asymptomatic Preserved LVEF < 110 bpm

Symptom evaluation : EHRA score

Clot control : Anticoagulant p revention of systemic thromboembolism

Valvular AF  VKA for all

Antithrombotic Therapy to Prevent Stroke in Patients who Have Nonvalvular AF (Meta-Analysis) Adapted with permission from Hart et al. Adjusted-dose warfarin compared with placebo or control Antiplatelet agents compared with placebo or control Adjusted-dose warfarin compared with antiplatelet agents

Recommendations CORLOE For patients with nonvalvular AF with prior stroke, transient ischemic attack, or a CHA 2 DS 2 -VASc score of 2 or greater, oral anticoagulants are recommended. Options include: warfarin (INR 2.0 TO 3.0), or IA dabigatran, or IB rivaroxaban, or IB apixaban. IB

RecommendationsCORLOE For patients with nonvalvular AF and a CHA 2 DS 2 -VASc score of 0, it is reasonable to omit antithrombotic therapy. IIaB For patients with nonvalvular AF and a CHA 2 DS 2 -VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. IIbC

Risk of bleeding : HASBLED  Hypertension : SBP> 160 mmHg  Abnormal renal and liver function - Chronic dialysis, renal transplant, serum creatinine ≥ 200 mmol/L ( 2.26 mg/dL ) - Chronic hepatic disease ( cirrhosis ), bil > 2 x UNL, AST, ALT > 3 x UNL  Stroke  Bleeding - Previous bleeding Hx and /or predisposition to bleeding – bleeding diathesis, anemia  Labile INRs - Unstable / High INR or poor time in therapeutic range < 60%  Elderly : >65 yr  Drug or alcohol - Use antiplatelet, NSAID, alcohol abuse High risk Point ≥ 3

Optimal INR  INR 2.0 – 3.0 for prevent systemic emboli in Nonvalvular AF  INR 1.8 – 2.5 in elderly ( not based on any large trial evidence )  CYP2C9 and VKORC1 genotypes – influence warfarin dose requirement and asso with bleeding event

Specific patient groups and AF  ACS - DC if unstable situation ( hypotension or shock, HF, persistent angina) - VKA with CHA2DS2-VASc score  Hypertrophic cardiomyopathy - VKA independent of CHA2DS2-VASc score  Hyperthyroidism - VKA with CHA2DS2-VASc score - BB for rate control

Specific patient groups and AF  COPD - VKA with CHA2DS2-VASc score - Nondihydropyridine CCB for rate control  HFpEF - BB or Nondihydropyridine CCB for rate control - caution needed in patients with overt congestion, hypotension, or HFrEF  HFrEF -Digoxin or Amiodarone for rate control  Postoperative AF

AF with WPW and Pre-excitation syndrome

WPW ( Wolf-Parkinson-White syndrome)  Short PR interval <120 msecs.  QRS > 100 msecs.  Delta wave = slurred upstroke at beginning of QRS.

Type A Positive QRS in V1

Type B Negative QRS in V1

RecommendationsCORLOE Prompt direct-current cardioversion is recommended for patients with AF, WPW syndrome, and rapid ventricular response who are hemodynamically compromised. IC Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium channel antagonists (oral or intravenous) in patients with WPW syndrome who have pre-excited AF is potentially harmful because these drugs accelerate the ventricular rate. III: Harm B