ATRIAL FIBRILLATION

INTRODUCTION
• A SV arrhythmia, low amplitude baseline oscillation
with irregularly irregular ventricular rhythm
• f-waves v/s flutter waves
• Heart rate – 100 – 160 per min (if WPW then…)
• Conditions when AF appears more regular- :

CLASSIFICATION OF AF

MECHANISMS
• Multiple re-entrant waves
• Rapidly discharging autonomic foci
• Single re-entrant circuit with fibrillatory conduction

CAUSES OF AF
• Cardiac causes
- Ischemic
- Non ischemic
• Non cardiac
- Thyrotoxicosis
- Alcohol
- Drugs
- Obesity, OSA
- Pneumonia
- Trauma, Sepsis

CLINICAL FEATURES
• Palpitation
• Fatigue
• Dyspnea
• Effort intolerance
• Light headedness
• Polyuria
• Syncope
• O/E

DIAGNOSTIC EVALUATION
• Onset, duration, random/particular times
• TFT, RFT, Electrolytes, LFT, CXR, ECHO
• ECG, Holter, etc

MANAGEMENT
OF ATRIAL
FIBRILLATION

CLASSIFICATION OF AAD

PATIENT MANAGEMENT :
THE INTEGRATED A B C Pathway

I. ANTICOAGULATION / AVOID STROKE

STROKE PREVENTION

LAA closure
• PREVAIL and PROTECT trial
• Non inferior to VKA

II. BETTER SYMPTOM CONTROL

0

INDICATIONS FOR CATHETER ABLATION

DRUG ROUTE DOSE C/I or RECAUTIONS or COMMENTS
AMIODARONE Oral 200 mg TDS X 4 wks
then 200 mg OD
Most effective, stop if QTc is >500 ms, ECG
repeat after 4 weeks
FLECAINIDE Oral 100 – 200 mg BD C/I in IHD and HFrEf, discontinue if QRS
widen >25% and in pt. with LBBB, ECG after
2 wks
PROPAFENONE Oral 150 – 300 mg TDS C/I in CKD, CLD. Discontinue if QRS widen
>25% and in pt. with LBBB, ECG after 2 wks
DRONADARONE Oral 400 mg BD Less effective than amiodarone. Not be used
in NYHA class III or IV or unstable HF.
Discontinue if QTc > 500 ms. ECG after 4
weeks
SOTALOL Oral 80 – 160 mg BD Not be used in HFrEF, significant LVH,
prolonged QT, asthma, hypokalaemia, CKD.
ECG after 1 day and 2 weeks
DISOPYRAMIDE Oral 100 – 400 mg BD or
TDS
Rarely used as it increases mortality. May be
useful in vagal AF

III. CARDIOVASCULAR RISK FACTOR AND
CONCOMITANT DISEASE
• Lifestyle intervention
- Obesity and weight loss
- Alcohol and caffeine
- Physical activity
• Specific cardiovascular risk factor / comorbidities
- Hypertension
- Heart failure
- Coronary artery disease
- Diabetes
- Sleep apnea

RECOMMENDATIONS

CKD AND AF
• CKD is pro-thrombotic and AF increases CKD
• In mild to moderate CKD (> 30 ml/min/m2)
same recommendations
• For < 30 or post transplant data lacking

PAD AND AF
• OAC unless contraindicated
• If with stable vascular disease the manage
with OAC alone
• NDDC referred over β- blocker

ENDOCRINE DISORDER AND AF
• Data are limited
• Stroke prevention on same principles
• In hyperthyroidism
- Amiodarone
- RFA

GI DISORDERS AND AF
• IBD increases risk of stroke and AF
• Apixa / Dabigatran === Warfarin
• Dabigatran should be given post meal
• Same principles apply to CLD cases

HEMATLOGICAL DISORDER AND AF
• Anemia is independent predictor of OAC related
major bleed.
• Platelet < 1 lakh requires expert opinion
• Both should be investigated and corrected , if
possible.

THE ELDERLY AND AF
• Receive less OAC
• Anti-platelets neither more effective nor safer
• OAC >>>>>> Warfarin (risk : benefit profile)
• Abnormal INR ↑ risk of dementia

THANK YOU