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Atrial Fibrillation….Atrial Fibrillation….
Robert Minera D.O. PGY-IVARMC Emergency Medicine
Atrial Fibrillation….Atrial Fibrillation….aka Pennington aka Pennington
SyndromeSyndromeRobert Minera D.O. PGY-IVARMC Emergency Medicine
EpidemiologyEpidemiology
• Most frequently diagnosed arrhythmia • Affects 2.3 million people in the US• Affects 1/136 people in the US• Incidence increases with age • 8% of people >80 yrs. old
Signs and SymptomsSigns and Symptoms
• Palpitations• Weakness• Dizziness• Reduced exercise capacity• Dyspnea• Asymptomatic
Etiology/Risk FactorsEtiology/Risk Factors• Structural heart disease• Chronic lung disease• Pneumonia• Hyperthyroidism• Alcohol use• Pulmonary embolism• HTN• Pericarditis
Differential DiagnosisDifferential Diagnosis
• Narrow Complex Tachycardias– Atrial Fibrillation– Atrial Flutter– AVNRT– AVRT– Atrial tachycardia– Sinus tachycardia– Multifocal atrial tachycardia
SVT is a category, not a diagnosis!
ACC/AHA/ESCACC/AHA/ESC
• Paroxysmal: terminates in < 7 days
• Persistent: fails to terminate within 7 days
• Permanent: > 1 year• Lone: Individuals without structural
heart disease, < 60 yrs old
Diagnostic Testing: EKGDiagnostic Testing: EKG
Narrow Complex
Irregularly Irregular
Rapid Ventricular Rate
Diagnostic Testing: TTEDiagnostic Testing: TTE
• To assess for structural heart disease– EF– Wall motion– Dilation/Hypertrophy– Size of right and left atrium– Valvular disease– Pericardial disease
Chest X-RayChest X-Ray
• Look for emphysema/COPD• Cardiac borders• Pneumonia
ManagementManagement
• Rate Control• Rhythm Control• Anticoagulation• Unstable patients
Rate ControlRate Control
• Why is rate control important?– Ischemia, MI, hypotension can occur– Long term: Cardiomyopathy
• Goals– Rest HR < 80 bpm– 24 Hour (Tele/Holter) < 100 bpm average– HR < 110 in 6 minute walk
Rate Control (con’t)Rate Control (con’t)
• Medications– Metoprolol / Esmolol: IV or Oral– Diltiazem: IV or Oral– Verapamil: Oral Only– Digoxin: Patients with hypotension– Amiodarone: Also for rhythm control
Rhythm ControlRhythm Control
• Indications– Symptoms of a-fib persistent– To avoid long term anticoagulation– Bleeding risk
Rhythm Control (con’t)Rhythm Control (con’t)
• Synchronized DC cardioversion– Emergencies/Hemodynamic instability– Greater efficacy than medications
• Pharmacologic cardioversion– If AF < 7days – dofetilide, flecainide,
ibutilide, propaferone or amiodarone– If AF > 7 day – dofetilide or amiodarone
Rate or Rhythm Control?Rate or Rhythm Control?
• AFFIRM Study: Rate versus rhythm control– No difference in incidence of stroke– Trend towards lower mortality in the rate
control group– This is STILL a controversial topic!– New study focusing on rhythm
conversion-Ottawa Protocol
Anticoagulation and Anticoagulation and CardioversionCardioversion
• Afib < 48 hours: – Cardioversion (CV)– No anticoagulation
indicated
• Afib > 48 hours: – Anticoagulate for
3-4 weeks before CV
– OR get TEE
– Anticoagulate for 1 month after CV
Anticoagulation – Long Anticoagulation – Long TermTerm
• Risk of CVA determined by CHADS2 score (CHF, HTN, >75, DM, Previous CVA x 2)
Score Annual Stroke Risk %
0 1.9
1 2.8
2 4.0
3 5.9
4 8.5
5 12.5
6 18.2
Key PointsMost patients, can wait
48 hours before starting
0-1 probably don’t need anticoagulation
5-6 should be bridged with heparin/LMWH
Management – UnstableManagement – Unstable
Unstable: A-fib associated with Hypotension
Synchronized electric Cardioversion immediately
Key PointsKey Points
• MI is a rare CAUSE of a-fib• Rate control must be achieved
during exercise, not just at rest• Not every patients needs to bridge
with heparin• Unstable patients should
immediately be cardioverted