AF tips

Rate control No HFB-blocker or CCB or combo Decompensated low EF HFNo B-blocker or CCB Use Dig or Amio + diuresis/HF therapy Decompensated Nl EF HFMay use B-blockers or CCB Compensated low EF HFB-blocker

Goals of rate control: # <110 (or better <100) at rest is an acceptable goal if symptoms controlled with such a lenient rate and if LV function is normal (RACE II trial) # <80 at rest and <115 with moderate exertion if pt is symptomatic with the higher rate target or if impaired LV function

Indications for rhythm control? 1.AF that is symptomatic despite rate control 2.Symptomatic first presentation of AF, even if symptoms improved with rate control (give them one chance!) 3.AF + new HF or severely decompensated HF -AF + new HF  always think of the possibility of tachycardia-mediated cardiomyopathy and be aggressive with AF

Otherwise, if symptoms well controlled with rate control, rate control is non-inferior to rhythm control (rate control s associated with same % of hard CV events as rhythm control, with a tend to being slightly better, according to AFFIRM and RACE trials)

Predictors of failure of rhythm control and frequent need to accept permanent AF LA diameter> 5 cm AF persistent>1 yr Previous recurrences of persistent AF requiring≥ 2 cardioversions

CHA2DS2 VAS CHF = 1 point HTN = 1 point Age > 75 yrs = 2 points DM = 1 point Prior Stroke or TIA = 2 points V=Vascular disease (CAD, PAD) A=Age S=Sex (female)

Short AF case 1 54 yom presents with shock (BP 75/50, obtunded) AF rate 127 Next step?

AF is secondary to shock state rather than causing shock state, esp. when rate<150  would not DC cardiovert, would look for causes of shock In case of AF + shock state, consider other potential causes of shock before attributing it to AF

Short AF case 2 54 yom, known to have low EF 25%, presents with ADHF (pulmonary edema on CXR). He is found to have AF rate of 120 on ECG Rate control?

Give diuresis and vasodilators  AF rate will improve with HF therapy. AF may even convert to sinus with HF therapy as it un-”streches” the left atrium May give digoxin

Short AF case 3 76 yom, hx of HTN. Asymptomatic Found to have irregular pulse on exam and AF rate of 110 Next step?

Anticoagulation (CHA2DS2-VAS score of 3) Since he is asymptomatic, do not rhythm control Rate control to <