Management of Atrial Fibrilillation: Dr. Dilip Kumar Jain Dr. Rajmani
Management of Atrial Fibrilillation: Dr. Dilip Kumar Jain Dr. Rajmani
Management of Atrial Fibrilillation: Dr. Dilip Kumar Jain Dr. Rajmani
MANAGEMENT OF ATRIAL
FIBRILILLATION
BY:
Dr. DILIP KUMAR JAIN
Under the guidence of
Dr. RAJMANI
Asst. Prof. Medicine Deptt.
J.L.N. Medical College & Hospital
Ajmer-305001
REFRENCES
HARRISON’S principles of Internal
Medicine 17th edition
BRAUNWALD’S Heart disease 8th
edition
LEOSCHAMROTH’S An
introduction to Electro Cardiography 7th edition
Various internet sites
ATRIAL FIBRILLATION
AF: It is an arrhythmias characterized by seemingly disorganized
atrial depolarization without effective atrial contraction.
AF is most common sustained arrhythmias.
Incidence- very common
1% > 60 years
75%> 69 years
From framingham data lifetime risk after age 40 years
26% Men
23% Women
Men> Women
AF is common in adult population .It is extremely unusual in
children unless structural heart ds in present or there is another
arrhythmia that precipitate the AF such as PSVT with WPW
syndrome.
Independently associated with : H/O CHF, Valvular heart disorder,
stroke , Left atrial enlargement, abnormal aortic or mitral valve
function , treated systematic HTN, advanced age, obesity.
Occasionally AF occur in
:--Acute hyperthyroidism
:--Acute Vagotonic episode
:--Acute alcohol intoxication
:--Common during the acute or early Recovery
phase of major vascular ,abdominal or thoracic surgery .
Also be triggered by after supraventricular tachycardia such
as AVNRT.
ECG
Small irregular baseline undulation of variable amplitude and
morphology call f-wave at rate of 350-600 beat/min.
ventricular response is grossly irregular (Irregularly- irregular)
and untreated pt normal AV conduction is usually b/w 100-160
beat/min ,in patient with WPW syndrom VR during AF can
exceed 300 beats/min and lead to VF. AF should
be suspected when ECG show supraventricular complex at an
irregular rhythm and no obvious P wave. In long standing
cases of AF, the deflexsion is low amplitude and the baseline
almost straight with minimal smooth low amplitude undulations.
Physical Findings:
Slight variation in intensity of 1st heart sound.
Absent of a-wave in JVP
Irregularly irregular ventricular rhythm
often fast ventricular rate, a significant pulse deficit.
If VR become regular in AF conversion into sinus rhythms atrial
tachycardia, AFL constant ratio of conduction beat or development of
junctional tachycardia or VT should be suspected.
Symptom :
1. Asymptomatic
2. Only minor palpitation or sense irregularity of their pulse
3. Severe palpitation
4. Anginal symptom
5. Exercise intolerance & easy fatigability are hallmark of poor rate control
with exertion .
6. Occasionally the only manifestation severe dizziness or syncope a/w pause
that occur upon termination of AF before sinus rhythm resume.
MECHANISM
AF initiation & maintenance appear to represent a complex interaction
b/w driver responsible for initiation and complex anatomical atrial
substance that promote the maintenance of multiple wavelets of (micro)
re-entry. The drivers appear that enter pulmonary vein also documented
around the orifice of pulmonary vein and non-pulmonary vein.
Four Important aspects :
1. Treatable contributory factor
2. Control of ventricular rate
3. Prevention of recurrence
4. Prevention of thromboembolic episode.
CLINICAL IMPORTANCE RELATED TO
1. Loss of atrial contractility .
2. Inappropriate fast ventricular response
3. Loss of atrial appendage contractility & emptying lead to risk of clot
formation and subsequent thromboembolic event.
EMBOLISATION & ANTICOAGULATION
Risk of systemic emboli probably arising in left atrial cavity or
appendage.
Non-valvular AF is the most common cardiac disease a/w
cerebral embolism.
Half of cardiogenic emboli occur in patient with non-valvular
AF.
Risk of stroke in patient with non-valvular AF 5-7 time greater
than control without AF.
Overall 20-25 ischemic stroke caused by cardiogenic
embolism.
Risk factor that predict stroke in non-valvular AF
include:
---H/o previous stroke or TIA (RR 2.5)
---H/o DM (RR1.7)
---H/o HTN (RR1.6)
---Increasing age (RR 1.4 for each decade)
---Annual stroke risk at least 4% if untreated
Only stroke risk factor -- CHF
-- CAD
LVDF & LA size > 2.5/m2 on echocardiographic examination are
a/w with thromboembolism.
Patient younger than 60-65 yrs who have echocardiogram & no
risk factor have extremely low risk for stroke.
Risk of stroke with lone AF is relatively low
Anticoagulation therapy is 50% more effective than aspirin
therapy for prevention of ischemic stroke in AF patience.
Risk factor anticoagulation associated brain hemmorhage:-
1.Exessive anticoagulation
2. Partially controlled HTN
Individuals younger than 60 yrs. Of age without any clinical risk
factor or structural heart ds (lone AF) not require anti-thrombotic
therapy for stroke prevention (b/c low risk factor )
Stroke rate is also low in age of 60 and 75 years with lone atrial
fibrillation. These Patience adequately protected from stroke by
ASPIRIN therapy.
In very elderly patience >75 yrs with AF anticoagulation should
be with caution & carefully monitored because of the potentially
increased risk of intra cranial hemmorhage.
RECOMMENDATION FOR
ANTITHROMBOTIC THERAPY
Any patience with AF who has risk factor for stroke should be
treated with warfarin to achieve INR 2-3 for stroke prevention.
Prior stroke
TIA
Significant valvular heart ds
HTN
DM
>65 years
LA enlargement
CAD
CHF
Contradiction to anticoagulation & unreliable individual should
be considered for Aspirin therapy.
Patience with AF who do not have any preceding risk factor
have a low stroke risk & can be protected from stroke with
Aspirin.
In patience > 75 years anticoagulation should be used with
caution & monitored carefully to keep INR less than 3.0
(because risk of intra-cranial hemmorhage)
Risk of Embolisation following cardioversion to sinus
rhythm in AF varies from 0 to 7% :----
:-depending on under lying risk factor
:-independent of mode of cardio-version
:-High Risk Prior embolism
Mechanical valve-prosthesis
Mitral Stenosis
:-Low Risk Patience < 60 yrs without underlying heart ds
High risk group should receive chronic anticoagulation
regardless of whether they will undergo cardio version.
Patience not in low risk group who have AF longer than 2
days should receive warferin for 3 week before elective
cardio-version (Keep INR 2-3), for 3-4 weeks after
reversion to sinus rhythm.
Alternative strategy TEE (Tran-esophageal
echocardiogram) to exclude the presence of atrial thrombus.
It predict group at risk for Development of
thromboembolism follower cardiogram that the patient are
immediately treated with Heparin followed by therapeutic
dose of warferin.
Anticoagulation with Heparin has been recommended
foremergency cardio version when 3 weeks of anticogulation or
Tran esophageal echocardiogram can't be obtained.
No matter which strategy is used anticoagulation should be
continued for at least 4 weeks following cardio-version
Newer strategies for stroke prevention in AF
ORAL THROMBIN INHIBITOR
Eg Ximelagatran
Melagatran
Wide therapeutic window not requiring monitoring.
OBLITERATION OF LEFT ATRIAL
APPENDAGE
Non rheumatic AF more than 90% thrombi from LA appendage.
Surgical closure is recommended only as adjuvant procedure in
patient undergoing mitral valve surgery.
PLAATO PROCEDURE:-
Percutaneous LAA trascatheter occlusion via the
transeptal approach.
Expanding nitinol cage is placed under transoesophageal
echocardiography guidance and allowed to expand in LAA thus
filling it and effectively excluding it from the circulation.
It is not appropriate for anticoagulation.
EVALUTION