atria

1. Atrial fibrillation

2. Definition
• AF is characterised by disorganised, rapid, and irregular atrial
activation with loss of organized atrial mechanical contraction
and with an irregular ventricular rate that is determined by AV
nodal conduction

4. RISK FACTORS
• INCREASING AGE
• HYPERTENSION
• DIABETES MELLITUS
• MI
• VHD
• HF
• OBESITY
• OBSTRUCTIVE SLEEP APNEA
• CARDIOTHORACIC SURGERY
• SMOKING
• EXERCISE
• ALCOHOL
• HYPERTHYROIDISM
• INCREASED PULSE PRESSURE
• EUROPEAN ANCESTRY
• FAMILY HISTORY
• GENETIC VARIANTS
• ECG- LVH
• 2D ECHO
– LA ENLARGEMENT
– DECREASED LV FRACTIONAL SHORTENING
– INCREASED LV WALL THICKNESS
• BIOMARKERS
– CRP
– BNP
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016

6. (AF begets AF)

7. CLINICAL FEATURES
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016

8. ALFA STUDY S LEVY ET AL 1999

9. PHYSICAL EXAMINATION
• Irregular pulse
• Irregular JVP
• Variations in intensity of First Heart sound
• Cardiac murmur
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016

10. INVESTIGATIONS
• ECG
• Chest radiograph
• 2D ECHO
• Serum electrolytes
• Complete blood count
• RFT, LFT
• LIPID PROFILE, HbA1c
• TFT
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016

11. INVESTIGATIONS
• INR
• BNP
• SLEEP STUDY
• TEE
• ELECTROPHYSIOLOGIC STUDIES
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016

12. ECG
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016

13. Management

14. Guidelines
AHA/ACC AF guideline 2014 ESC AF guideline 2016

15. Rate control
Rhythm
control
Stroke
prevention
Manage
precipitating
factor
Acute
management

16.  Vitals ?
Hemodynamically unstable
Hypotension
Cardiac ischemia
Pulmonary edema
DC cardioversion
Start anticoaguation immediately
and continued for 4weeks
f/u after 4weeks to decide for
long term anticoagulation
New onset AF
DC Cardioversion
 150 to 200 J to start with,
may go up to 360J
 Highly effective (95 %)
 If fails, start Ibutilide infusion
before next shock

17.  Vitals ? • <48hrs – cardioversion f/b
3-4weeks anticoagulation
• >48hrs/not known
 early cardioversion after
excluding thrombus by TEE
 3-4 weeks anticoagulation f/b
cardioversion and anticoagulation
• Electrical cardioversion is more
effective than pharmacologiacal
New onset AF
Hemodynamically stable
AF with FVR
Ventricular Rate control
Cardioversion

18. Rate control

19. Ventricular Rate control
What are the drugs ?
How to choose ??
Dose Side effects
Metoprolol 2.5-10mg IV
100-200mg daily oral
Bradycardia, AV block,
lethargy, headache,
upper respiratory tract
symptoms
Carvedilol 3.125-50mg BD
Nevibolol 2.5–10 mg OD
Diltiazem 15-25 mg bolus IV
60-120mg TDS
dizziness, lethargy,
headache, edema
Digoxin 0.0625–0.25 mg OD gastrointestinal
Upset, arrhythmia
Amiodarone 200 mg daily Pulmonary toxicity,
thyroid dysfunction,
corneal deposits

21. Rhythm control
• What are the Drugs
Dose Side effects
Propafenone Oral 150-300 TDS Arrhythmia, blurring
of vision
Flecainide 100-150mg BD Arrhythmia,
confusion
Sotalol 80-160mg BD Arrhythmia
Amiodarone IV -15mg/min x 10min, 1mg/min
x 3hrs, 0.5mg/min up to 24 hrs
Oral- 600 mg in divided
doses for 4 weeks, 400 mg
for 4 weeks, then 200 mg
once daily
Arrhythmia
Lung disease
Corneal deposit
Thyroid disorder
Dronedarone 400mg BD Arrhythmia,
transient rise in Cr.

23. Maintenance of sinus rhythm

24.  Amiodarone is most effective,
 In view of extracardiac adverse effects, should be
kept as last resort in recurrent AF/AF with heart
failure

25. Catheter ablation
 Indications-
• symptomatic persistent AF
not responding to AAD
• Can be considered as first line
therapy in young symptomatic AF
considering patient choice, risk, benefit, side effects of AAD
 Challenges-
• Arrhythmia substrate is poorly understood, widespread,
variable between patients, progressive
 recurrence

26. Anticoagulation

27. Risk stratification

29. Oral anticoagulants
VKA
 INR monitoring
 Drug interaction
 Delay in onset and weaning of action
 Narrow therapeutic range
NOAC (Non VKA Oral
Anticoagulants)
• Rivaroxaban
• Apixaban
• Edoxaban
• Dabigatran
 Usually preferred over VKA
 Not recommended in mechanical
heart valve and mod-severe MS
 Renal dose modification
 High cost

30. Secondary prevention
 TIA- start anticoagulation after 1
day
 Stroke- start anticoagulation
after 3-12 days considering
severity of stroke

31. Risk of bleeding- HASBLED score
 Should be used as cautionary “yellow flag” for more stringent
monitoring with more severe score

32. Left atrial appendage occlusion/exclusion
• In case of contraindication to long term anticoagulation
• Surgical excision or closure by suturing/stapling is successful
only in 40% of cases
• Post op TEE should rule out thrombus before discontinuation
of anticoagulation
• Percutaneous left atrial appendage occlusion device- newer
method (LAAO)
• Non inferior to warfarin
(PROTECT-AF trial)

33. References
• AHA guidelines for AF 2014 and 2019 update
• ESC guideline for AF 2016
• Harrison’s Internal medicine 21st edition
• UpToDate 2022
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES
2016