Atrial fibrillation resident survival guide
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]
Definition
Atrial fibrillation (AF or Afib) is a cardiac arrhythmia that originates in the atria of the heart.
Causes
Life Threatening Causes
Life-threatening conditions which may result in death or permanent disability within 24 hours if left untreated.
- Congestive heart failure
- Dehydration
- Electrolyte disturbance
- Hypothermia
- Hypoxia
- Myocardial infarction[1]
- Myocarditis
- Pericarditis
- Pheochromocytoma
- Pulmonary embolism[2]
- Uremic pericarditis
Common Causes
Management
Newly Discovered Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with newly discovered atrial fibrillation:
Newly discovered AF | |||||||||||||||||||||||||||||||||||||
Paroxysmal | Persistent | ||||||||||||||||||||||||||||||||||||
No therapy needed unless severe symptoms (e.g., hypotension, HF, angina pectoris | Accept permanent AF | Rate control and anticoagulation as needed | |||||||||||||||||||||||||||||||||||
Anticoagulation as needed | Anticoagulaion and rate control* as needed | Consider antiarrhythmic drug therapy | |||||||||||||||||||||||||||||||||||
Cardioversion | |||||||||||||||||||||||||||||||||||||
Long term antiarrhythmic drug therapy unnecessary | |||||||||||||||||||||||||||||||||||||
ADD indicates antiarrhythmic drugs
*See figure 5
Algorithm based on the 2011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Recurrent Paroxysmal Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with recurrent paroxysmal atrial fibrillation:
Recurrent paroxysmal AF | |||||||||||||||||||||||||||||||||
Minimal or no symptoms | Disabling symptoms in AF | ||||||||||||||||||||||||||||||||
Anticoagulation and rate control as needed | Anticoagulation and rate control as needed | ||||||||||||||||||||||||||||||||
No drug for prevention of AF | Antiarrhythmic drug therapy* | ||||||||||||||||||||||||||||||||
AF ablation if ADD treatment fails | |||||||||||||||||||||||||||||||||
ADD indicates antiarrhythmic drugs
*See figure 5
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Recurrent Persistent Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with recurrent persistent atrial fibrillation:
Recurrent persistent AF | |||||||||||||||||||||||||||||||||
Minimal or no symptoms | Disabling symptoms in AF | ||||||||||||||||||||||||||||||||
Anticoagulation and rate control as needed | Anticoagulation and rate control | ||||||||||||||||||||||||||||||||
Antiarrhythmic drug therapy* | |||||||||||||||||||||||||||||||||
Electrical cardioversion as needed | |||||||||||||||||||||||||||||||||
Continue anticoagulation as needed and therapy to maintain sinus rhythm* | |||||||||||||||||||||||||||||||||
Consider ablation for severely symptomatic recurrent AF after failure of greater than or equal to 1 ADD plus rate control | |||||||||||||||||||||||||||||||||
ADD indicates antiarrhythmic drugs
*See figure 5. Initiate drug therapy before cardioversion to reduce the likelihood of early recurrence of AF.
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Permanent Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with permanent atrial fibrillation:
Permanent AF | |||||||||||||||||||||||||||||||
Anticoagulation and rate control* as needed | |||||||||||||||||||||||||||||||
*See figure 5
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Antiarrhythmic Drugs Used in Atrial Fibrillation
Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation:
Drugs are listed alphabetically and not in order of suggested use.
The seriousness of heart disease progresses from left to right, and selection of therapy in patients with multiple conditions depends on the most serious condition present.
LVH indicates left ventricular hypertrophy.
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Do's
Atrial fibrillation nomenclature
- Paroxysmal - recurrent, transient, last less than 7 days, terminate without therapeutic intervention.
- Persistent - last more than 7 days, terminate with therapeutic intervention.
- Permanent - last > 1 year, can't be converted or conversion not attempted.
- Lone Afib - without any structural heart disease
Drug choices for rate control
- Beta blocker metoprolol/lopressor, atenolol/tenormin.
- Non-dihydropyridine calcium channel blockers diltiazem/cardizem, verapamil.
- Digoxin can be used as a second line drug.
- If drug therapy fails cardioversion with 100 joules of electricity can be tried. Prior to an elective cardioversion either a negative TEE or 3-4 weeks of anticoagulation is required. Post cardioversion 4 weeks of anticoagulation is recommended.
- Hemodynamic stability is first priority, rate control 2nd.
- Hypotension could be rate related so treatment should not be avoided.
- Cardioversion should be done in hemodynamically unstable patients.
- Important points to remember for anti-arrhythmic drugs:
- Sotalol and Dofetelide - monitor QTc interval for prolongation for 48 hrs post initiation. QTc >= 500 or 15% above baseline may increase the risk of Torsades. Check daily EKG or EKG 2 hours post the drug dose
Anticoagulation for atrial fibrillation
- CHADS2 score
- Congestive heart failure - 1
- Hypertension -1
- Age > 75 -1
- Diabetes Mellitus -1
- Stroke or TIA - 2
- Score > 2 anticoagulate
- Score < 2 Aspirin may be sufficient
- CHA2DS2 VASc score
- Congestive heart failure - 1
- Hypertension -1
- Age > 75 - 2
- Diabetes Mellitus -1
- Stroke or TIA - 2
- Vascular disease - 1
- Age - 65 -74
- Sex - Female
- Score 0 low risk, no anticoagulation or aspirin 81-324
- Score 1, moderate risk, oral anticoagulation or Aspirin
- Score 2 or more, oral anticoagulation
- CHADS2 score
Don't
References
- ↑ Zimetbaum, PJ.; Josephson, ME.; McDonald, MJ.; McClennen, S.; Korley, V.; Ho, KK.; Papageorgiou, P.; Cohen, DJ. (2000). "Incidence and predictors of myocardial infarction among patients with atrial fibrillation". J Am Coll Cardiol. 36 (4): 1223–7. PMID 11028474. Unknown parameter
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ignored (help) - ↑ Goldhaber, SZ.; Visani, L.; De Rosa, M. (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218. Unknown parameter
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ignored (help) - ↑ 3.0 3.1 3.2 3.3 3.4 Fuster, V.; Rydén, LE.; Cannom, DS.; Crijns, HJ.; Curtis, AB.; Ellenbogen, KA.; Halperin, JL.; Kay, GN.; Le Huezey, JY. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 123 (10): e269–367. doi:10.1161/CIR.0b013e318214876d. PMID 21382897. Unknown parameter
|month=
ignored (help)