1. Ali Alsayegh, MD, FRCPC,FACC Consultant Cardiologist, Consultant Cardiac Electrophysiologist

2. One AF is relatively common and Challenging

3. Prevalence of Atrial Fibrillation Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults. JAMA. 2001; 285:2370- 2375

4. Clinical Events (outcomes) affected by AF

5. Two Types of AF

6. Clinical Types

7. Pathophysiological Types AF cause by trigger with normal left atrium (substrate). Possible cure AF without trigger but abnormal substrate. Progressive

8. Three Patient profile very well

9. Common coexistent conditions European Heart Journal. ESC Guidelines

10. EHRA score of AF- related symptoms AF = atrial fibrillation; EHRA = European Heart Rhythm Association

11. CHADS 2 score and stroke rate

12. Risk factor-based point-based scoring system - CHA 2 DS 2 -VASc

13. The HAS-BLED bleeding risk score

14. Four Treatment Options

15. Rate and rhythm control of AF. Mortality outcome The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators

16. Aliot E, and Ruskin J N Eur Heart J Suppl 2008;10:H32-H54 Predictor of Mortality In AFFIRM

17. Five Prevent Stroke Before It Happens

18. Highly preventable (65% RRR)

19. Six Novel New Anticoagulants

20. Approved agents for the prevention of stroke in patients with AF

21. Antiplatelet agents used for stroke prophylaxis in patients with AF

22. Seven Rate Control is not Bad in Many Patients

23. Optimal level of heart rate control

24. Rate control of atrial fibrillation

25. AV node ablation in AF patients a Class of recommendation. b Level of evidence. AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy; LV = left ventricular; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.

26. Wood M et al. Circulation 2000;101:1138-1144 Quality of life and symptoms after AV junctional ablation and pacing

27. Choice of pacemakers after AV node ablation

28. Eight Rhythm control: Drug

29. Principles of antiarrhythmic drug therapy to maintain sinus rhythm 1. Treatment is motivated by attempts to reduce AF-related symptoms. 2. Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest. 3. Clinically successful antiarrhythmic drug therapy may reduce rather than eliminate recurrence of AF. 4. If one antiarrhythmic drug ‘fails’ a clinically acceptable response may be achieved with another agent. 5. Drug-induced proarrhythmia or extra-cardiac side-effects are frequent. 6. Safety rather than efficacy considerations should primarily guide the choice of antiarrhythmic agent.

30. Chance of Staying in Sinus Rhythm

31. Choice of antiarrhythmic drug according to underlying pathology

32. Nine Rhythm control: Left Atial Ablation

33. Current approaches to catheter ablation Catheter ablation is currently based on four main strategies: Isolation of the triggers and perpetuating re-entrant circuits located in the pulmonary veins; Disruption of the substrate for perpetuating rotors in the antra of the pulmonary veins; Disruption of putative dominant rotors in the left and right atria, recognized by high-frequency complex fractionated electrograms during mapping of AF. Targeted ablation of ganglionated autonomic plexi in the epicardial fat pads.

34. Pulmonary veins isolation

35. Success Rate of AF Ablation

36. Rhythm control more likely to succeed Recent Onset AF No structural heart disease Small LA Younger Age Reversed precipitating factor

37. Ten Newer Therapeutic options

38. Blood thinner alternative: Left Atrial Occlusion Device

39. Investigational Antiarrhythmic Agents

40. Summary for AF Management from ESC Guidelines

41. Thank You