Atrial Fibrillation

Atrial Fibrillation

1. Risk Factors

   • NOT FROM LECTURE NOTES
   • Post-Operative (Open Heart Surgeries)
   • Pericarditis
   • "Lone" AF
     • NO RISK FACTORS at all and still has AF...
   • Cardiac Causes
     • Hypertension
     • Heart Failure
     • Ischaemic Heart Disease
     • Rheumatic Heart Disease
     • Sinus-sinus syndrome
       • Tachy-Brady syndrome
     • Wolff-Parkinson-White Syndrome
     • Cardiomyopathy
   • Non Cardiac Causes
     • Acute Infections
     • Electrolyte depletion
     • Lung Carcinoma
     • Pleural Effusion
     • Pulmonary Embolism

2. What happens in AF

   • It is a type of Arrhythmia
     • Atria are fibrillating, not a normal contraction ---> STAGNANT Blood Flow
       • Leading to a rapid, irregular Ventricular Rate
         • Decreased Ventricular filling and output
           • This leads to these SYMPTOMS
             • Fatigue
             • Shortness of Breath
             • Chest discomfort
             • Palpitations
             • Feeling faint
       • Blood Clot
         • Stroke
         • Heart Attack
         • Pulmonary Embolism
           • Blood Clot in the Lung

3. Rate Control

   • Medicines
     • Beta-Blockers & Non-dihydropyridine CCB are first line
       • Metoprolol, Atenolol, Propranolol, Carvedilol Diltiazem, Verapamil. All DECREASE BP. Slow the HR 
     • Digoxin - Second line
       • HR often increase with exercise
   • Procedures
     • Pacemakers
       • Prevents Heart from going too slow but can do nothing with heart going too fast. That is why antiarrhymic drugs are given.
     • AV node ablation
       • A type of surgery that involves burning.

4. Rhythm Control

   • Medicines
     • Most likely prescribed these medications for sinus rhythm maintenance or preventing AF occuring
     • Amiodarone
       • Best Efficacy/Effectiveness. Problems: Toxicity in brain, liver, kidney, thyroid, skin.
     • Flecainide
     • Pill In Pocket
   • Cardioversion
     • Restarting the heart.  Very successful - AF to normal sinus rhythm 

5. Diagnosis of AF

   • Paroxysmal AF (Self-Terminating)
     • <7 days (Most resolve within 24 hours)
     • Rhythm Control FIRST
       • Rate Control if rhythm fails
   • Persistent AF (Not Self-Terminating)
     • > 7 days - sustained AF that terminates with cardioversion
     • Rate OR Rhythm Control depending on conditions
       • Rhythm first in patients who are: Symptomatic Younger (<65) Presenting for first time with Lone AF Secondary to precipitant Congestive Heart Failure 
       • Rate first in patients who are: Over 65 With Coronary Heart Disease Contraindications to anti-arrythmic drugs Unsuitable for cardioversion 
       • Try other if previous fails
   • Permanent AF (Cannot go back to Normal)
     • Persists for more than a year, cardioversion has failed or not even attempted
     • Rate Control FIRST
       • Rhythm Control (if rate fails)
         • Opposite of Paroxysmal  methods Karo :)
   • New Onset of AF
     • Patient is Hemodynamically Stable
       • Anticoagulated INR 2-3 for >3 weeks
         • Cardioversion
         • Rate Control
       • Not anticoagulated INR <2 for 3 weeks
         • Warfarin and Rate Control
         • Cardioversion
   • Recurrent AF
     • I don't know if we've learnt it this way...
     • Minimal Symptoms
       • Warfarin and Rate Control
         • No prevention. No Anti-arrythmic drugs
     • Disabling Symptoms
       • Warfarin and Rate Control
         • Anti-arrythmic drugs for prevention

6. Warfarin INR 2-3