Presentation

• A 28 yo male with no prior cardiac history

presents complaining of palpitations,
lightheadedness and decreased exercise tolerance
for the last 6 hours. The symptoms came on
suddenly at 4 AM, awakening him from sleep.
He had been up the night before drinking heavily.
• No significant medical history.
• No medications
• No smoking
• Occasional binge drinking
• BP 100/60, Pulse 140 and irregularly
irregular, RR 18
• Rest of exam is normal, except heart
sounds, which are irregularly irregular with
variable intensity S1.
 Atrial Fibrillation
The lifetime risks at age 40 years for developing the disorder were 26%
(95% CI 24–27%) for men and 23% (21–24%) for women
1st detected vs. recurrent (>2 episodes)
Lone AF = age <60 and w/o clinical or echo evidence of cardiac disease
including HTN
Paroxysmal (self terminating usually within 24 hrs) vs. persistent(>7d) vs.
permanent (>1yr when cardioversion has failed)
Acute: due to cardiac (CHF, pericarditis, etc), pulmonary (PE,
pneumonia, etc), metabolic ( high catecholamine states, thyrotoxicosis) or
drugs/alcohol
Chronic: due to age, HTN, ischemia, thyroid, obesity, valvular disease
 Risk Factors for Atrial
Fibrillation (2.3 Million Patients)
• Age (3.8% of U.S. population > 60; 9.0 % > 80)
• Hypertension
• Coronary artery disease
• Cardiomyopathy
• Valvular disease (primarily mitral)
• Hyperthyroidism
• Excessive alcohol intake
• Pulmonary disorders including pulmonary embolism
• After cardiac surgery
• Myocarditis or Pericarditis
• Obstructive sleep apnea
 Work-Up
• H&P
• ECG (verify the presence of Afib)
• CXR (look for pneumonia, CHF, pulmonary
cause)
• Thyroid Function Tests (TFTs)
• Echocardiogram (check PA pressures, left
ventricular function, left atrial size, valvular
disease)
• Consider stress test to test if ischemic/exercise
induced Afib
 Atrial Fibrillation:
Acute Management
• Control ventricular rate (which can be quite fast [180-200] in the
young healthy patient):
–  blockers: especially effective in post-op/high catecholamine
states
– Ca2+ blockers: quicker onset v. beta blockers
– Digoxin: useful in hypotensive patients
– Combinations of the above
– Watch for hypotension
• Expect spontaneous cardioversion in 50-67% with acute AF w/in
24 hrs
• Target <100 resting heart rate
 Atrial Fibrillation:
Acute Management
• Consider urgent cardioversion (drugs or
electrical) if patient is unstable
– Potassium channel blockers
• Ibutilide
• Dofetilide
– Sodium channel blockers
• Propofenone
• Flecainide
– Amiodarone
 Atrial Fibrillation: Acute Management
• Consider cardioversion (drugs or electrical)
– Potassium channel blockers (prolong action potential)
• Ibutilide (intravenous, feared to cause polymorphic ventricular
tachycardia)
• Dofetilide (oral, may also cause polymorphic VT)
• Sotalol (do not use in patients with low EF)
– Sodium channel blockers
• Propofenone (oral, can cause ventricular arrhythmias)
• Flecainide (oral, this drug may also cause ventricular arrhythmias,
shown to kill people in the CAST study)
– Amiodarone (least pro-arrhythmic. Use in patients with any form of
structural heart disease including CAD)
• Cardioversion in pts w/1st episode of AF or in those w/sx. If >48hrs, get
TEE to r/o thrombus. If high risk patient (mitral stenosis, prior emboli),
anti-coagulate for 3 wks before attempting cardioversion/INR >2
• Increase likelihood of success if <7d
 How do you maintain sinus
rhythm?
• First question: do you need to?
– Answer: Maybe not, unless patient is hard to rate
control or symptomatic when in AF. Also like to try
if it’s the first episode.
• Second question: what can you use if everything
is deadly?
– Beta blockers help and control rate if return to AF.
– Amiodarone seems safest long term (low dose) in
patients with other cardiac disease, but agents like
propofanone and flecainide are preferred if there’s
no other cardiac disease whatsoever.
AFFIRM Trial: No advantage for
rhythm control
• Rhythm control group had 6 times as many
episodes of polymorphic VT.
• Rhythm control group had twice as much
bradycardia.
• Strokes occurred in both the rate and
rhythm control groups
 Stroke in AF
• 5% to 6% annual risk of embolic stroke
• Higher in patients with:
– Prior stroke
– Diabetes
– Hypertension history
– Heart failure history
– Age > 60
• >10% in the setting of rheumatic valvular disease.
• Lifelong warfarin reduces risk substantially even
s/p cardioversion
 Preventing Thromboembolic
Stroke
• Do not cardiovert if patient known to be in atrial
fibrillation for longer than 48 hours without first
getting transesophageal echocardiogram (TEE) to
verify there is no clot.
• If uncertain of timing of onset, don’t take a
chance: get a TEE.
• Lifelong warfarin if in high risk group.
• Aspirin sufficient in the low risk group.
• Use the CHADS2 risk score to determine need for
warfarin in non-valvular AF.
 CHADS2 Score for Stroke Risk
in non-valvular Atrial Fibrillation
Condition Points

Congestive heart failure (any history) 1

Hypertension (prior history) 1

Age ≥ 75 1

Diabetes mellitus 1

Secondary prevention in patients with a prior ischemic 2

stroke, transient ischemic attack, systemic embolic event
Score = 0 Aspirin
Score = 1-2 Individualize (Warfarin if “S”)
Score = 3 or greater Warfarin
 Stroke Risk
• Whether the atrial fibrillation is chronic,
intermittent (so-called paroxysmal atrial
fibrillation), or requires medication for
rhythm control, the risk of stroke is
increased and justifies the use of
anticoagulation
• 90% of pts have asymptomatic afib,
90%>48hrs, always risk of thrombus!
 If other treatments don't work:
• Ablate the AV node.
• Place a permanent pacemaker.
• Not an ideal scenario:
– Lack of physiological rate dependence
– Foreign body forever
– Pulse generator changes
– Hard to do an MRI
 What about our patient?
• He received 15 mg of metoprolol IV push in
3 divided doses over 15 minutes.
• His heart rate dropped to 110 and he felt much
better.
• Echo and CXR were normal. He had no signs or
symptoms of hyperthyroidism.
• He was given 600 mg oral propofanone, and
converted to sinus rhythm 2 hours later. After
another 6 hours of observation for arrhythmias, he
was discharged home on one 325 mg aspirin a
day. He has had no further episodes  Lone AF