ATRIAL FIBRILLATION

RATE CONTROL VS RHYTHM CONTROL

AF WORKSHOP 2014

PERMANENT AF

AF that decided to be permanent because - cannot be terminated in what means of treatment, - low success or unlikely to achieve sinus rhythm, - failed cardioversion - decided not to try cardioversion - when the presence of the arrhythmia is accepted by the patient (and physician). Usually long standing Most have significant structural heart disease.

Treatment strategy RATE CONTROL

PERSISTENT AF
AF episode either :

-lasts longer than 7 days or -requires termination by cardioversion - DRUGS - DC SHOCK

Treatment strategy PRIORITY : RATE CONTROL

Studies have shown no difference in term of mortality outcome or rate stroke among patient with persistent AF converted to sinus rhythm vs rate controlled

PERSISTENT AF
AF episode either :

-lasts longer than 7 days or -requires termination by cardioversion - DRUGS - DC SHOCK

Treatment strategy RHYTHM CONTROL IF

Patient still symptomatic despite rate controlled Younger patients Those presenting for the first time with lone AF Those with AF secondary to a treated/corrected precipitant Those with persistent congestive heart failure.

PAROXYSMAL AF

AF occurs and terminates by itself Usually resolves spontaneously within 48 hrs up to 7 days

TREATMENT STRATEGY

NO SYMPTOMS NO RX

MINIMAL SYMPTOMS RATE CONTROL

DISABLING SYMPTOMS RHYTHM CONTROL

OPTIMAL RATE CONTROL

Priority is rate control first in most cases Decision for rhythm control depend on physician & patients & certain conditions Previously aim of ventricular response: rest : 60-80/min moderate exercise : 90-115/min Latest guideline : rest or exercise < 100/min (CCS guidelines) or < 110/min (AHA/ACC/ESC guidelines)

OPTIMAL RATE CONTROL

EXCEPTION - VALVULAR STENOSIS - LV DYSFUNCTION - HEART FAILURE - ACUTE CORONARY SYNDROME - HOCM - CERTAIN INDIVIDUALS

NEED LOWER VENTRICULAR RESPONSE RATE

NON ACUTE , MINIMAL SYMPTOMS AF

ACUTELY SYMPTOMATIC AF

PATIENT STABLE RATE < 100 -150/MIN ORAL DRUGS

PATIENT SYMPTOMATIC UNSTABLE & NOT FOR CARDIOVERSION RATE > 100 - 150/MIN CONDITIONS NEED RAPID RATE CONTROL IV DRUGS

OPTIMAL RATE CONTROL

NON ACUTE , MINIMAL SYMPTOMS AF

ACUTELY SYMPTOMATIC AF

ORAL DRUGS :

IV DRUGS :

BLOCKER CALCIUM CHANNEL BLOCKER DIGOXIN AMIODARONE

BLOCKER CALCIUM CHANNEL BLOCKER DIGOXIN AMIODARONE

Can use in combination except precaution & best avoid Verapamil + blocker

Also for patient unable to take oral drugs eg : acute CVA ,post surgery

OPTIMAL RATE CONTROL

ORAL DRUGS TO CONTROL RATE

blocker
- Metoprolol : 25-100mg BD - Atenolol : 25mg -100mg OD - Bisoprolol : 1.25-10mg OD - Carvedilol : 6.25-25mg BD - Propanolol : 20-120mg BD

Calcium channel blocker

- Diltiazem : 30-120mg TDS - Verapamil : 40-120mg TDS

Digoxin
- Load : 0.5mg stat

Amiodarone*
- Load : 400-800mg BD 1 week

- Maintain: 0.0625-0.375mg OD

- Maintain : 200mg OD

*USE WHEN OTHER DRUG CONTRAINDICATED OR INEFFECTIVE

WHAT IS THE BEST ORAL DRUG

The best are - Blocker - Verapamil - Diltiazem Digoxin is a poor rate control drug esp. in pt with hyperadrenergic state EXCEPT - SEDENTARY SITUATION - HYPOTENSION - HEART FAILURE Do not use digoxin solely in paroxysmal AF

Amiodarone useful in : - HYPOTENSION - HEART FAILURE - OTHER DRUGS CONTRAINDICATED OR INEFFECTIVE Can use in combination for better control, try avoid combination involving Verapamil-higher risk of AV block

IV DRUGS TO CONTROL RATE

blocker
- IV Metoprolol :
Bolus - 5mg over 2 min, repeat every 5min till total 15mg
- IV Propanolol : Bolus - 1mg over 2min, repeat every 5min till total 5mg - IV Esmolol : Bolus : 0.5mg/kg over 1min can repeat 0.25-0.5mg/kg boluses Infusion : 0.05mg/kg/min over 4min

Calcium channel blocker

- IV Verapamil : 2.5-5mg over 3min repeat 30min later 5-10mg over 3min if needed

Amiodarone - Load : 5mg/kg over 1hr or 150mg over 10min - Maintain : 50mg/hr infusion or 300mg in 50ml D5% at 8ml/hr infusion

Digoxin
- Infusion : 0.5mg in 100ml NS over 1-2hr repeat 0.25mg every 6hr till total 1mg

OTHER TIPS.
Avoid Verapamil if hypotension, heart failure or LV dysfunction. If hypotension, heart failure or LV dysfunctionuse amiodarone or digoxin if cardioversion not performed or ineffective. Digoxin slow onset, narrow therapeutic index ineffective in high sympathetic conditions (sepsis, thyrotoxicosis ) - avoid in significant renal dysfunction

URGENT ELECTRICAL CARDIOVERSION

INDICATIONS HAEMODYNAMICALLY UNSTABLE

Hypotension : SBP < 100 mmHg
Heart failure/Acute pulmonary oedema. Uncontrolled angina or ongoing myocardial ischaemia/infarction. Impaired cerebral perfusion: ~ unconscious. ~ fit. Preexcited AF eg WPW

IV HEPARIN OR SC LMWH DC cardioversion - synchronous ( monophasic: 200J-300J-360J ). ( biphasic :100J-150J-200J ). If succesful achieved sinus rhythm bridging therapy Oral anticoagulant for 4 weeks Reassess if need further anticoagulantnt

IV heparin : 70u/kg bolus (max 5000u) & 15u/kg/hr (max1000u) with APTT LMWH : SC Enoxaparin 1mg/kg BD