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Atrial Fibrillation quick review. Updated to december 2013.
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Asociación Cardiovascular Centroccidental ASCARDIO
European Society of Cardiology
Francisco J. Chacón-LozsánUCLA-Venezuela
ASCARDIOEuropean Society of Cardiology:
ACCA, HFA, e-cardiology, EACPR, Hypertension and Heart.2014
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Definition
•Atrial reentrant tachycardia.
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ECG criteria
•No P waves.•Presence of oscillatory waves with low amplitude called “f” waves with a rate of 350-600dpm.•PR non measurable.•RR variable.
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Classification
•Low ventricular response.• HR<60dpm
•Normal ventricular response.• HR 60-100dpm
•Fast ventricular response.• HR>100dpm
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•Histopathology classification.
Primary: Without other causes.
Secondary: Related to a cardiac or systemic cause.
Classification
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•Chronologic.
Classification
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•Levy’s.
Group I. First symptomatic attack.A: Self limiting.B: Require treatment.
Group II. Non treated patients with recurrences.A: Asymptomatic, recurrent identified.B: Recurrences in more of 3 months.C: Recurrences in less then 3 months.
Classification
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•Levy’s.
Group III. Patients with recurrences despite treatment. A: Detected by ECGB: Recurrences after 3 months.C: Recurrences before 3 months.
Classification
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Multiple waves hypothesis. Random reentrant mechanism explains RR variability.
Pathophysiology
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Pathophysiology
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Pathophysiology
A. Unique atrial contraction focus close to pulmonary veins generate reentrant waves.
B. Reentrant waves originated in several ectopic focus in both atriums.
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“X” indicate the origin of the impulse. Vertical lines AV conduction. Diagonal lines AV node conduction and conduction around the reentrant circuit and perpendicular lines indicate blockade. AJR: Accelerate Junction Rhythm.; MAT: Multifocal atrial tachycardia.; PAT: Paroxistic Atrial Tachycardia.; RJT: Reentrant Junction tachycardia.; TACH, tachycardia.
Pathophysiology
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PathophysiologyNormal
contraction
Mitral regurgitation
Low cardiac output
Less coronary flux
Less cerebral flux
Lost of atrial contribution
Less fuelling time
Fibrillation
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Causes
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Causes
•Arrhythmias:• WPW.• Reentrant SVT.• Atrial tachycardia.• Circular movement tachycardia.• Sinus node disease. Who was first, the egg or the
chicken?• Vagal•Genetic: 10q22-q24
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ClinicEuropean Heart Rhythm Association (EHRA) score
AF-related symptoms.
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Rhythm Management
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Man
agem
ent
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Rhythm control Management and ablation
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ManagementCardioversion Drugs
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Rate control Management
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Rat
e co
ntr
ol M
anag
emen
t
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Clinical
ScenariosRivaroxaban Apixaban Edoxaban Betrixaban Dabigatran
CVD prevention
and systemic
embolism in AF
ROCKET AF
Japanese-AF
AVERROES
ARISTOTLEENGAGE AF EXPLORE Xa
RE-LY
RELY-ABLE
Anticoagulation Management
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Anticoagulation Management
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Acronym, year Region Drugs testedDoses of new
anticoagulant (mg)Other antiplatelet
drugs and doses (mg)
Petro, 2007
Europe,
North
America
Dabigatran vs warfarin
50, 150, 300; all twice daily
No aspirin, or 81 or 325 mg
Re-LY LD, 2009
Worldwide Dabigatran vs warfarin
110 mg twice
daily
Concomitant use of aspirin (at a dose of <100 mg per day) or other antiplatelet agents was permitted
Re-LY HW, 2009
Worldwide Dabigatran vs warfarin
150 mg twice
Daily
Concomitant use of aspirin (at a dose of <100 mg per day) or other antiplatelet agents was permitted
Weitz, 2010 Worldwide Edoxaban vs
warfarin
30, 60, 120 No restriction about aspirin
Anticoagulation Management
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Acronym, year Region Drugs testedDoses of new
anticoagulant (mg)
Other antiaplatelet
drugs and doses (mg)
ARISTOTLE J, 2011 Asia Apixaban vs warfarin 2.5; 5; all twice daily No restriction about
aspirin
ARISTOTLE, 2011 Worldwide Apixaban vs warfarin 5 twice daily
No restriction about
aspirin lower than 165
mg. Aspirin and
clopidogrel together
use were exclusion
criteria
Rocket AF, 2011 Worldwide Rivaroxaban vs
warfarin 20
Aspirin ≤100 mg
monotherapy and
thienopyridine
monotherapy allowed.
Chung, 2011 Asia Edoxaban vs
warfarin 30, 60
No restriction about
aspirin
Anticoagulation Management
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Check in each patient
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Anticoagulation ManagementCVD Risk and embolism
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Anticoagulation ManagementCVD Risk and embolism
Rivaroxaban
Low-dose edoxaban
High-dose edoxaban
Low-dose dabigatran
High-dose dabigatran
Apixaban
Warfarin
0 1 2 3 4 5 6 7 8 9 10
2,99
1,91
0,74
3,12
2,28
2,69
3,42
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Anticoagulation ManagementBleeding Risk
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Anticoagulation ManagementBleeding Risk
Rivaroxaban
Low-dose edoxaban
High-dose edoxaban
Low-dose dabigatran
High-dose dabigatran
Apixaban
Warfarin
0 1 2 3 4 5 6 7 8 9 10
7,48
4,32
8,61
5,96
6,86
5,11
7,34
%
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Anticoagulation ManagementBleeding Risk
CH
A2D
S2-
VA
Sc
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Anticoagulation ManagementBleeding Risk
HA
S B
LE
D
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Anticoagulation Management
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An
tico
agu
lati
on M
anag
emen
t
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Tromboprophylaxis in AF
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Tromboprophylaxis in AF
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References1. Wagner, Galen S. Marriot’s Practical Electrphysiology. 11th edition2. Sociedad Española de Cardiología. Primer curso de electrocardiografía de la SEC. 2010.3. Arango, Ramirez y Durango. Electrocardiografía y Arritmias. Sociedad Colombiana de
Cardiología. 2010.4. Charría y col. Texto de Cardiología. Sociedad Colombiana de Cardiología. 2007.5. Branwald’s Heart Disease. 9na edición. Editorial ELSAVIER. 2011.6. Heist y col. Rate control in Atrial Fibrillation: targets, methods, resynchronization considerations.
Circulation 2011, 124: 2746-2755.7. 2011 ACCF/AHA/HRS Focused update on the magnament of patients with Atrial fibrillation
(updating 2006 guidelines): a report of the American College of Cardiology Foundation/American Heart Association Task force on practice guidelines.
8. Camm y col. Guidelines for the magnaments of atrial fibrillation. European Heart Journal 2010. 31, 2369-2429.
9. Zipes. Cardial Electrophysiology. From cell to bedside. 5th edition. Saunders editorial.10. Heidbuchel et al. EHRA Practical guidelines on use of NOACs in patients with non-valvular AF
(2013) Europace 15, 625-651.
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Thanks…http://ve.linkedin.com/in/chaconlozsanfrancisco/
