1. Atrial Fibrillation Update 2012 Dr C Seifer Section of Cardiology St Boniface Hospital

2. Case 1  86 yo female  Hypertension and Coronary Artery Disease  > 10 year history of persistent (permanent) atrial fibrillation  Difficult to rate control  Admitted with CHF and atrial fibrillation with ventricular rate 120-130 bpm

3. Case 1  LVEF (MUGA) 27%  On metoprolol 100 mg TID and amiodarone 200 mg daily (nausea)

4. Case 1  What next?

5. Case 1  What next? Increase/Add medications Increase/Add medications No further intervention No further intervention Consider pacing and AV node ablation Consider pacing and AV node ablation

6. Case 1  What next? Increase/Add medications Increase/Add medications No further intervention No further intervention Consider pacing and AV node ablation Consider pacing and AV node ablation

7. Case 1  What next? Increase/Add medications Increase/Add medications No further intervention No further intervention Consider pacing and AV node ablation Consider pacing and AV node ablation  Anticoagulation?

8. Can J of Cardiol 2012;28:125-136.

11. Case 2  76 yo female 12 hours post hip replacement  History of hypertension and DM2  Symptoms of palpitations  HR 140 bpm and BP 140/80  ECG confirms atrial fibrillation

12. Case 2  Management

13. Case 2  Management Rhythm control? Rhythm control? Rate control? Rate control?

14. Case 2  Management Rhythm control? Rhythm control? Rate control? Rate control? MetoprololMetoprolol DiltiazemDiltiazem

16. Case 3  48 yo male  Attends for physical  Denies any significant symptoms symptoms but not very active (truck driver)  HR 100 bpm irreg irreg BP 130/80  ECG confirms atrial fibrillation  Started on ASA and atenolol  ECHO: Mildly dilated LA, normal left ventricle

17. Case 3  What next? Rhythm control Rhythm control Rate control Rate control

18. Case 3  What next? Rhythm control Rhythm control D/C cardioversionD/C cardioversion ± Antiarrhythmic drugs± Antiarrhythmic drugs Rate control Rate control

20. Case 4  54 yo healthy male  Two episodes of symptomatic atrial fibrillation in the past 1 year  No other co-morbidities  Started on Metoprolol and Flecainide  Two subsequent episodes of AF – one requiring D/C cardioversion  Started on amiodarone – hyperthyroid  No structural heart disease

21. Case 4  What next?

22. Case 4  What next? Another drug trial Another drug trial No change in management No change in management Pacemaker and AV node ablation Pacemaker and AV node ablation Ablation (PVI) Ablation (PVI)

23. Case 4  What next? Another drug trial Another drug trial No change in management No change in management Pacemaker and AV node ablation Pacemaker and AV node ablation Ablation (PVI) Ablation (PVI)

24. Can J of Cardiol 2012;28:125-136.