#1009 Evaluation & Management of Atrial Fibrillation

November 16 to 19

Stephen F. Schaal, MDProfessor of Internal MedicineDivision of CardiologyThe Ohio State University Medical Center

Robert Hoover, MDAssistant Professor of Internal MedicineDivision of CardiologyThe Ohio State University Medical Center

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Stephen F. Schaal, MDProfessor of Internal Medicine

Division of CardiologyThe Ohio State University Medical Center

Profile Profile

Mrs. Greer• 73 year old female• Presented with palpatationsEvaluation• Exercise study - PVC’s• Rate dependent LBBB• Cardiac catheterization

Findings• Normal coronary arteries

Mrs. Greer• 73 year old female• Presented with palpatationsEvaluation• Exercise study - PVC’s• Rate dependent LBBB• Cardiac catheterization

Findings• Normal coronary arteries

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Profile Profile

Mrs. Greer• MVP; mild mitral regurgitation• Normal left ventricular function• Very small ASD

Side effects• Palpatations / trachycardia• Atrial flutter-sotalol started• Weight gain

Mrs. Greer• MVP; mild mitral regurgitation• Normal left ventricular function• Very small ASD

Side effects• Palpatations / trachycardia• Atrial flutter-sotalol started• Weight gain

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Atrial Fibrillation Atrial Fibrillation

Common EtiologiesCardiac• Vavular heart disease - Mitral stenosis insufficiency - Mitral valve prolapse - Aortic valve disease - Tricuspid valve disease

• Hypertension cardiovascular disease• Cardiomyopathy• Ischemic heart disease• Pericardial disease• Conduction system disease (“lone”)

Common EtiologiesCardiac• Vavular heart disease - Mitral stenosis insufficiency - Mitral valve prolapse - Aortic valve disease - Tricuspid valve disease

• Hypertension cardiovascular disease• Cardiomyopathy• Ischemic heart disease• Pericardial disease• Conduction system disease (“lone”)

Endocrine• Hyper, hypothyroidism• Pheochromocytoma

Pulmonary• Pulmonary emboli• Obstructive pulmonary disease

Metabolic / Drug• Acute alcohol• Cocaine• Theophylline, catecholamines

Endocrine• Hyper, hypothyroidism• Pheochromocytoma

Pulmonary• Pulmonary emboli• Obstructive pulmonary disease

Metabolic / Drug• Acute alcohol• Cocaine• Theophylline, catecholamines 6

Electrophysiologic Substrate For Atrial Fibrillation

Electrophysiologic Substrate For Atrial Fibrillation

• Disparate atrial ERPs• Fragmented conduction

• Atrial stretch

• Autonomic dysfunction

• Disparate atrial ERPs• Fragmented conduction

• Atrial stretch

• Autonomic dysfunction

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Evaluation Of Atrial FibrillationEvaluation Of Atrial Fibrillation

• History - Duration - Symptoms - Presence of heart disease - Drugs, toxins - State of anticoagulation - Other disease• Physical Examination - Cardiomegaly - Valvular disease - Pericardial disease - Thyroid disease - Other• ECG• Chest x-ray• Echocardiogram

• History - Duration - Symptoms - Presence of heart disease - Drugs, toxins - State of anticoagulation - Other disease• Physical Examination - Cardiomegaly - Valvular disease - Pericardial disease - Thyroid disease - Other• ECG• Chest x-ray• Echocardiogram 8

Consequence Of Atrial FibrillationConsequence Of Atrial Fibrillation

• Hemodynamic compromise - Atrial enlargement and disorganized atrial depolarization atrial dysfunction - Varying atrial and ventricular rate AV valve dysfunction - Inappropriate acceleration of heart rate with exercise, stress Result: possible fatigue, dyspnea, CHF, angina

• Electrophysiologic compromise - Atrial fibrillation begets atrial fibrillation

• Thromboembolic compromise - Stroke - Other systemic or pulmonic emboli

• Hemodynamic compromise - Atrial enlargement and disorganized atrial depolarization atrial dysfunction - Varying atrial and ventricular rate AV valve dysfunction - Inappropriate acceleration of heart rate with exercise, stress Result: possible fatigue, dyspnea, CHF, angina

• Electrophysiologic compromise - Atrial fibrillation begets atrial fibrillation

• Thromboembolic compromise - Stroke - Other systemic or pulmonic emboli

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Stroke Risk Factors InAtrial Fibrillation

Stroke Risk Factors InAtrial Fibrillation

• Age (Framingham)• Rheumatic heart disease (Framingham)• Poor left ventricular function or recent CHF (SPAF)• Enlarged left atrium (SPAF)• Previous myocardial infarction (AFASAK)• Hypertension (SPAF)• History of previous thromboembolic event (SPAF)• Presence of left atrial thrombus, atrial contrast, or reduced atrial appendage flow (by TEE)

• Age (Framingham)• Rheumatic heart disease (Framingham)• Poor left ventricular function or recent CHF (SPAF)• Enlarged left atrium (SPAF)• Previous myocardial infarction (AFASAK)• Hypertension (SPAF)• History of previous thromboembolic event (SPAF)• Presence of left atrial thrombus, atrial contrast, or reduced atrial appendage flow (by TEE) 10

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Considerations For Maintaining Normal Sinus Rhythm

Considerations For Maintaining Normal Sinus Rhythm

• Physiologic control of ventricular rate• Atrial contribution to cardiac output• Better exercise tolerance• Thromboembolic risk probably reduced• Risks of long-term anticoagulation therapy may be avoided, especially if warfarin contraindicated• Tachycardia-induced cardiomyopathy controlled• Occasional AF recurrence is not drug inefficacy

• Physiologic control of ventricular rate• Atrial contribution to cardiac output• Better exercise tolerance• Thromboembolic risk probably reduced• Risks of long-term anticoagulation therapy may be avoided, especially if warfarin contraindicated• Tachycardia-induced cardiomyopathy controlled• Occasional AF recurrence is not drug inefficacy 13

Recovery Of Atrial Mechanical Function After Restoration Of Sinus Rhythm

Recovery Of Atrial Mechanical Function After Restoration Of Sinus Rhythm

• Technique: doppler atrial filling wave with peak velocity 0.5 m / s (Manning et al)

• Cardioversion, drug, spontaneous conversions Patients (%) Recovery Interval 20 within 6 hours >50 by 1st day >75 by 1st week 92 (drug or spontaneous) by day 3

• Technique: doppler atrial filling wave with peak velocity 0.5 m / s (Manning et al)

• Cardioversion, drug, spontaneous conversions Patients (%) Recovery Interval 20 within 6 hours >50 by 1st day >75 by 1st week 92 (drug or spontaneous) by day 3

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Vagally Mediated AF (A Form Of Lone AF)Vagally Mediated AF (A Form Of Lone AF)

• Occurs during high vagal tone - Postprandial - Sleep - Rest - Post exercise• Not related to sick sinus syndrome• Preceded by slowing of heart rate• Digitalis should be avoided• Rarely progresses to permanent AF• Rarely a pure syndrome

• Occurs during high vagal tone - Postprandial - Sleep - Rest - Post exercise• Not related to sick sinus syndrome• Preceded by slowing of heart rate• Digitalis should be avoided• Rarely progresses to permanent AF• Rarely a pure syndrome 16

Summary Summary

Mrs. Greer

Diagnosis - Mitral valve prolapse - Left atrial enlargement - Atrial flutter / atrial fibrillation

Mrs. Greer

Diagnosis - Mitral valve prolapse - Left atrial enlargement - Atrial flutter / atrial fibrillation

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Summary Summary

Mrs. Greer• Treatment - Increased amiodarone - Brady / tachy with fatigue, junctional rhythm - AV sequential pace - AV node ablation - Repeat ablation

Prognosis: Good

Mrs. Greer• Treatment - Increased amiodarone - Brady / tachy with fatigue, junctional rhythm - AV sequential pace - AV node ablation - Repeat ablation

Prognosis: Good 17A

Robert Hoover, MD Assistant Professor of Internal Medicine

Division of CardiologyThe Ohio State University Medical Center

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Therapeutic Approaches To Atrial Fibrillation

Therapeutic Approaches To Atrial Fibrillation

• Anticoagulation• Antiarrhythmic suppression• Control of ventricular response - Pharmacologic - Catheter modification / ablation of AV node • Curative procedures - Surgery (maze) - Catheter ablation

• Anticoagulation• Antiarrhythmic suppression• Control of ventricular response - Pharmacologic - Catheter modification / ablation of AV node • Curative procedures - Surgery (maze) - Catheter ablation 19

Current Recommendations

For Anticoagulation Therapy For Atrial Fibrillation

Current Recommendations

For Anticoagulation Therapy For Atrial Fibrillation

• INR 2.0 - 3.0 for appropriate patients

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• Warfarin (INR 2.0 - 3.0) or ASA 325 mg / day in patients without clinical or echocardiographic risk factors

• INR 2.0 - 3.0 for appropriate patients

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• Warfarin (INR 2.0 - 3.0) or ASA 325 mg / day in patients without clinical or echocardiographic risk factors

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Role Of Echo In Atrial FibrillationRole Of Echo In Atrial Fibrillation

• Identify structural heart disease• Identify LVH• Identify increasing LA size

• Detect “smoke”

• Detect clot in LA

• Identify structural heart disease• Identify LVH• Identify increasing LA size

• Detect “smoke”

• Detect clot in LA21

Role Of TEE In Atrial FibrillationRole Of TEE In

Atrial Fibrillation

• Transesophageal echo is more sensitive (92%) and specific (98%) for detecting atrial clot

• Thromboembolic event is presumably due to left atrial clot

• Most clots are in left atrial appendage but poorly visualized by transthoracic surface echo

• Transesophageal echo is more sensitive (92%) and specific (98%) for detecting atrial clot

• Thromboembolic event is presumably due to left atrial clot

• Most clots are in left atrial appendage but poorly visualized by transthoracic surface echo 22

Rationale For Precardioversion TEE

Rationale For Precardioversion TEE

• Absence of clot on TEE may obviate need for anticoagulation

• Avoiding delay necessary for prolonged anticoagulation prior to cardioversion increases likelihood of successful cardioversion and maintenance of normal sinus rhythm

• Absence of clot on TEE may obviate need for anticoagulation

• Avoiding delay necessary for prolonged anticoagulation prior to cardioversion increases likelihood of successful cardioversion and maintenance of normal sinus rhythm 23

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Atrial Fibrillation: Areas Of ResearchAtrial Fibrillation: Areas Of Research

• AFFIRM study - National Heart Institutes atrial fibrillation study - Heart rate control and anticoagulation vs. rhythm control with antiarrhythmic drugs

• Patient-activated or automatic atrial defibrillator• Dual-site and biatrial pacing• Atrial pacing therapies for AF prevention• Catheter ablation therapies for AF - Catheter “maze” procedure - Ablation for “focal” AF

• AFFIRM study - National Heart Institutes atrial fibrillation study - Heart rate control and anticoagulation vs. rhythm control with antiarrhythmic drugs

• Patient-activated or automatic atrial defibrillator• Dual-site and biatrial pacing• Atrial pacing therapies for AF prevention• Catheter ablation therapies for AF - Catheter “maze” procedure - Ablation for “focal” AF 32

#1010 Asthma UpdateNovember 30 to December 3

Philip E. Korenblat, MDProfessor of Clinical MedicineWashington University School of MedicineSt. Louis, Missouri

Elizabeth Allen, MDAssociate Professor of Clinical PediatricsSection of Pulmonary MedicineChildren’s Hospital &The Ohio State University Medical Center

OMEN is OFF Thanksgiving Week

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