1. Atrial fibrillation (AF) and flutter
Domina Petric, MD

2. Atrial fibrillation Chaotic, irregular atrial rhythm at 300-600 bpm.
The AV node responds intermittently: irregular ventricular rate.
Cardiac output drops by 10-20%.
AF is common in the elderly.
The main risk is embolic stroke.

3. AF causes heart failure heart ischaemia arterial hypertension
myocardial infarction
pulmonary embolism
mitral valve disease
pneumonia

4. AF causes hyperthyroidism caffeine alcohol post-operative AF
hypokalemia
hypomagnesemia

5. AF causes cardiomyopathy constrictive pericarditis sick sinus syndrome
lung carcinoma
atrial myxoma
endocarditis
haemochromatosis
idiopatic

6. Symptoms
asymptomatic
chest pain
palpitations
dyspnoea
faintness

7. Signs Irregularly irregular pulse!
The apical pulse is greater than the radial rate.
First heart sound is of variable intensity.
There may be signs of left ventricular failure.

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Absent P waves, irregular QRS complexes.

9. Blood tests
Urea, electrolytes, kreatinine
Cardiac enzymes
Thyroid function tests

10. Other tests
Echocardiography: left atrial enlargement, mitral valve disease, poor left ventricle function and other structural abnormalities.

11. Conversion of atrial fibrillation
Within 48 hours from acute onset, propafenone 600 mg per os in patients without structural heart disease.
Within 48 hours, amiodarone
300 mg per os in patients with structural heart disease.
Electrocardioversion!

12. Conversion of atrial fibrillation >48 hours
Immediate electrocardioversion:
transesophageal echocardiography IJ LMWH OR
Electrocardioversion after 3 weeks of warfarin therapy.

13. Conversion of atrial fibrillation
Immediate electrocardioversion after period of 48 hours can be done only if transoesophageal echocardiography shows that the heart is thrombus free.

14. Alternative drug cardioversion
Amiodarone iv. 5 mg/kg over 1 h, then 900 mg over 24 hours via a central line.
Amiodarone 200 mg every 8 hours for 1 week, 200 mg every 12 hours next week and mg every 24 hours as a maintenance therapy.
Flecainide 2 mg/kg iv. over minutes, max. 150 mg OR 300 mg per os.

15. Flecainide
It can be used only if the patient is stable and there is no known ischaemic heart disease or Wolff-Parkinson-White syndrome.

16. Chronic AF
Main goals are:
rate control
anticoagulation

17. Rate control Beta blocker (BB) or rate-limiting Ca-blocker (CB).
Alternatives are digoxin and amiodarone.
BB should not be combined with diltiazem and verapamil!

18. Rhythm control Rhythm control is prefered in: symptomatic patients
congestive cardiac failure
younger patients
patients presenting for the first time with lone AF
AF from a corrected precipitant (electrolytes disbalance)

19. Rhythm control Electrocardioversion! Pharmacological cardioversion!
AV node ablation!
Maze procedure!
Pacing!
Pulmonary vein ablation!

20. Acute anticoagulation
LMWH in preparation for electrocardioversion.
Warfarin can also be used for elective electrocardioversion preparation.

21. Chronic anticoagulation
Anticoagulation with warfarin to aim for an INR 2-3.
Aspirin 300 mg per os can be used in patients with contraindications for warfarine use with very low risk of emboli.
Very low risk include younger than 65 years, NO hypertension, diabetes, LV dysfunction, rheumatic valve disease. past MI or TIA.

22. Contraindications for warfarin
bleeding diathesis
platelets <50 x 109/L
compliance issues
frequent falls
NSAID use
past intracranial bleeds
low haemoglobin

23. Chronic anticoagulation
Dabigatran is a direct thrombin inhibitor.
There is no need for regular laboratory INR monitoring and dose adjustment.
Dose is 110 mg every 12 hours per os.
Contraindications for dabigatran are severe renal and liver impairment, active bleeding, lesion at risk of bleeding, low level of clotting factors.

24. Interactions with dabigatran
heparin
clopidogrel
NSAIDS
GPIIb/IIIa antagonists
p-glycoprotein inhibitors like verapamil, amiodarone, clarithromycin

25. Atrial flutter
ECG: continous atrial depolarisation, heart rate usually 300 bpm, but very variable, sawtooth baseline and 2:1 AV block.

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27. Treatment Anticoagulation and electrocardioversion
Amiodarone, sotalol or BB
Cavotricuspid isthmus ablation

28. Literature
Oxford Handbook of Clinical Medicine. Longmore M. Wilkinson I. B. Baldwin A. Elizabeth W. Ninth edition.
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