1. Atrial Fibrillation Clinical Update
Dr. Amit Shah, MD FACC
Electrophysiology
Cardiology Consultants of West Alabama
August 21, 2018

2. Disclosures
None
Always willing to take money

3. Overview Clinical cases Pathophysiology Stroke prevention
Rate vs Rhythm control
Medication vs ablation for rhythm control
Review cases
New advancements & PEARLS
Questions

4. Case #1 67 yo WM HX of CAD s/p CABG, DM, HTN
Poor compliance
Presented to PMD for annual visit, no symptoms
Exam noted IRRRR
ECG shows AF with RVR

5. Case #2 74 yo WF Hx of symptomatic parox AF x 5 years, DM, HTN
Treated with sotalol, developed HB and has PPM
Continues to have palpiations and fatigue due to sotalol
On Eliquis 2.5 mg po BID

6. Case#3
55 yo WM
No PMH
Presented for feeling funny and checks BP/HR daily and today reads 130 bpm, never had this previously
No other symptoms
ECG shows AF

8. Pathophysiology
William Harvey ( ), the first to describe fibrillation of the auricles in animals in 1628.
The first human ECG depicting atrial fibrillation was published by Willem Einthoven ( ) in 1906.

10. Pathophysiology

12. Atrial fibrillation Stroke Prevention strategies
Rate vs rhythm control

16. CHADS2-VA2Sc

17. Anti-Coagulation Recommendations

18. Has Bled Score Bleeding risk

21. ELIQUIS VS ASPIRIN
From: Efficacy and safety of apixaban compared with aspirin in the elderly: a subgroup analysis from the AVERROES trial
Age Ageing. 2015;45(1): doi: /ageing/afv156
Age Ageing | © The Author Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please

22. Question #2 Rate vs Rhythm Control

23. Rate vs Rhythm Control

25. Rhythm control in CHF

26. Rhythm control does not confer a mortality benefit

27. Symptomatic Atrial Fib

29. Rhythm control strategy

30. Medical therapy for Maintenance of sinus rhythm

32. Rx vs Ablation
CABANA trial

33. What is Atrial Fibrillation Ablation?

34. Atrial Fibrillation Ablation
Surgical experience
Cox Maze

36. Cox Maze Surgery for AF

37. Catheter ablation

38. Surgical to endovascular

43. Cryotherapy vs RF

45. CABANA

47. Endpoints

49. COURAGE Trial

51. Final Answer?

52. Case #1 67 yo WM HX of CAD s/p CABG, DM, HTN
Poor compliance
Presented to PMD for annual visit, no symptoms
Exam noted IRRRR
ECG shows AF with RVR

53. Case #1 Stroke Prevention strategy CHADS2-VASC= 4 → OAC
Coumadin vs NOAC
Other meds are QD so Xarelto
Rate vs Rhythm control
No symptoms, rate control
CAD start with BB
Check ECHO,TSH, ect.

54. Case #2 74 yo WF Hx of symptomatic parox AF x 5 years, DM, HTN
Treated with sotalol, developed HB and has PPM
Continues to have palpiations and fatigue due to sotalol
On Eliquis 2.5 mg po BID

55. Case #2 CHAD VASC = 4 → OAC (on eliquis) Rate vs rhythm control
Drug refractory AF → ablation
Drug side effects,try to stop sotalol

56. Case#3
55 yo WM
No PMH
Presented for feeling funny and checks BP/HR daily and today reads 130 bpm, never had this previously
No other symptoms
ECG shows AF

57. Case #3 CHAD VASC = 0 Rate vs rhythm control
Aspirin is reasonable strategy
Rate vs rhythm control
Minimal symptoms
Attempt TEE/DCCV and see if significant improvement
Would hold on anti-arythmic agents
Given young age, discussion of ablation reasonable, but no mortality benefit

58. Advancements in Atrial fibrillation

59. Watchman

60. Micra Pacemaker

61. PEARLS

62. Sleep Apnea

63. Magnesium

64. Coffee

65. Questions

66. The End