D.BASEM ELSAID ENANYLECTURER OF CARDIOLOGY

AINSHAMS UNIVERSITY

Atrial fibrillation: Rate or rhythm

Rate or Rhythm?????

-Rate control should be the initial approach in elderly patients with AF and minor symptoms (EHRA 1) I.-Rate control should be continued throughout a rhythm control approach to ensure adequate control of the ventricular rate during recurrences of AF. I-Rhythm control is recommended in patients with symptomatic (EHRA>2) AF despite adequate rate control. I-Rhythm control in patients with AF and AF-related heart failure should be considered for improvement of symptoms. IIa-Rhythm control as an initial approach should be considered in young symptomatic patients in whom catheter ablation treatment has not been ruled out. IIa-Rhythm control should be considered in patients with AF secondary to a trigger or substrate that has been corrected (e.g. ischaemia, hyperthyroidism). IIa-Patient preference

--Factors that may influence the success of rhythm control long history of AF, older age, more severe associated cardiovascular diseases, other associated medical conditions, and enlarged LA size.--AFFIRM, RACE, AF-CHF no difference in morbidity or mortality--Waiting new scores to assess difference in quality of life==Two landmark studies, the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) and the Rate Control versus Electrical Cardioversion (RACE) trials, found that treating AF with a rhythm-control strategy, involving CV and antiarrhythmic drug (AAD) therapy, offers no survival or clinical advantages over a simpler rate-control strategy. However, these studies primarily enrolled older patients (older than age 65 years) with persistent AF who were mildly symptomatic. Moreover, in the AFFIRM study, fewer than two-thirds of those in the rhythm control arm were actually able to stay in sinus rhythm. Thus, the results cannot be extrapolated to many subgroups of patients, including younger patients; those with new, first-onset AF who may benefit from early conversion to sinus rhythm; patients with persistent AF who are highly symptomatic; and patients with significant systolic heart failure who have a hemodynamic benefit from the atrial kick.

Longterm rate control

--Rate control using BB, nondihydropyridine CCB, digitalis, or a combination is recommended in patients with paroxysmal, persistent, or permanent AFavoid bradycardia.--Symptoms related to AF during Activityshould be adjusted to achieve a physiological chronotropic response and to avoid bradycardia--In pre-excitation AFpropafenone or amiodarone.--It is reasonable to initiate treatment with a lenient rate control protocol aimed at a resting heart rate <110bpm.--Stricter rate control strategy when symptoms persist or tachycardiomyopathy occurs: resting heart rate <80 bpm , during moderate exercise <110 bpm24 h Holter monitor isrecommended to assess safety

--It is reasonable to achieve rate control by administration of dronedarone (400 mg b.i.d.) in non-permanent AF except NYHA class III–IV or unstable heart failure.--COPD: CCB, digoxin, small dose selective B1B--Digoxin is indicated in patients with heart failure and LV dysfunction, and in sedentary (inactive) patients.--Rate control may be achieved by administration of oral amiodarone when other measures are unsuccessful or contraindicated (IIb){amiodarone: 5 mg/kg in 1 h, and 50 mg/h maintenance, oral: 100 mg–200 mg o.d.}

Atrioventricular node ablation and modification

--When the rate cannot be controlled with pharmacological agents and when AF cannot be prevented by antiarrhythmic therapy or is associated with intolerable side effects, and direct catheter-based or surgical ablation of AF is not indicated, has failed, or is rejected (IIa)--Permanent AF and an indication for CRT?? (IIa)--CRT nonresponders in whom AF prevents effective biventricular stimulation and amiodarone is ineffective or contraindicated.(IIa)--In patients with paroxysmal AF and normal LV function, implantation of a dual-chamber (DDD) pacemakerwith mode-switch function may be considered after AV node ablation (IIb) , {persistant VVIR}

=Although the symptomatic benefits of AV nodal ablation areclear, limitations include the persistent need for anticoagulation, loss of AV synchrony, and lifelongpacemaker dependency.

Long-term rhythm control

Principles:(1) Treatment is motivated by attempts to reduce AF-relatedsymptoms.(2) Efficacy of antiarrhythmic drugs to maintain sinus rhythm ismodest.(3) Clinically successful antiarrhythmic drug therapy may reducerather than eliminate recurrence of AF.(4) If one antiarrhythmic drug ‘fails’, a clinically acceptableresponse may be achieved with another agent.(5) Drug-induced proarrhythmia or extra-cardiac side effects arefrequent.(6) Safety rather than efficacy considerations should primarilyguide the choice of antiarrhythmic agent

-- Amiodarone is more effective in maintaining sinus rhythm than sotalol, propafenone, flecainide or dronedarone—but toxicitywhen other agents have failed or are contraindicated (I)-- β-blockers should be considered for rhythm (plus rate) control in patients with a first episode of AF(IIa)-- Antiarrhythmic drug therapy is not recommended for maintenance of sinus rhythm in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning permanent pacemaker.

Disopyramide

--Dose: 100–250 mg t.i.d.--CI: systolic heart failure--Risky ECG findings: QT interval >500 ms --AVnodal slowing: none

Flecainide

--Dose: 100–200 mg b.i.d.--CI: creatinine clearance <50 mg/mL, in coronary artery disease, reduced LV ejection fraction--Risky ECG findings: QRS duration increase >25%above baseline--AVnodal slowing: none

Propafenone

--Dose: 150–300 mg t.i.d.--CI: coronary artery disease, reduced LV ejection fraction--Risky ECG findings: QRS duration increase >25%above baseline--AVnodal slowing: Slight

d,l-Sotalol

--Dose: 80–160 mg b.i.d.--CI: significant LV hypertrophy, systolic heart failure,pre-existing QT prolongation, hypokalaemia,creatinine clearance <50 mg/mL--Risky ECG findings: QT interval >500 ms--AVnodal slowing: as BB

Amiodarone

--Dose: 600 mg o.d. for 4 weeks, 400 mg o.d. for4 weeks, then 200 mg o.d.--CI: Caution when using concomitant therapy with QT-prolonging drugs, heart failure. Dose of vitamin K antagonists and of digoxin should be reduced.--Risky ECG findings:QT interval >500 ms--AVnodal slowing: 10–12 bpm in AF

Dronedarone

--Dose: 400 mg b.i.d.--CI: NYHA class III–IV or unstable heart failure, during concomitant therapy with QT-prolonging drugs, powerful CYP3A4 inhibitors, and creatinineclearance <30 mg/mL.--Risky ECG findings: QT interval >500 ms--AVnodal slowing: 10–12 bpm in AF

Left atrial catheter ablation

--Should be reserved for patients with AF which remains symptomatic despite optimal medical therapy, including rate and rhythm control.--In patients post-ablation, LMWH or i.v. UFH should be considered as ‘bridging therapy’ prior to resumption of systemic OAC, which should be continued for a minimum of 3 monthslongterm if CHA2DS2-VASc score>2--Complications:Thrombo-embolism, PV stenosis/occlusion(stent, high ISR), Atrio-oesophageal fistula formation, Tamponade, Phrenic nerve injury, Perioesophageal injury, Arteriovenous fistula, Aneurysm formation, Radiation injury, Mitral valve injury, Acute coronary injury, Air embolism, Haematoma at puncture site, Death(0.7%)

--Considering the potential of AF catheter ablation to achieve rhythm control in symptomatic patients with paroxysmal AF and minimal or no heart disease, and the relative safety of the technique when performed by experienced operators, ablation may be considered as an initial therapy in selected patients--Several prospective multicentre trials have now confirmed thesuperiority of catheter ablation compared with antiarrhythmicmedication--Atrial flutter ablation(bidirectional block in the inferior right atrial isthmus connecting the tricuspid annulus to the inferior caval vein—reentery--) class I--TOE is indicated

Surgical ablation

--AF is an independent risk factor for poor outcome after cardiac surgery and is associated with higher perioperative mortality--Restoration of sinus rhythm improves outcome IIa in symptomatic AF with cardiac surgery--Surgical ablation can easily achieve complete isolation with transmural lesions and also allows LAA exclusion/excision--Incisions (maze) or cryoablation, RF, high intensity focused US

1ry prevention

1-ACEIs and ARBs should be considered for prevention of newonset AF in patients with heartfailure and reduced ejection fraction, HTN (IIa)2-Statins should (IIa) be considered for prevention of new-onset AF after coronary artery bypass grafting,isolated or in combination with valvular interventions.

2ry prevention (IIb)

ARBs or ACEIs may be useful for prevention of recurrent paroxysmal AF or in patients with persistentAF in the absence of significant structural heart disease if these agents are indicated for otherreasons (e.g. hypertension).

Atheletes

--When a ‘pill-in-the-pocket’ approach with sodium channel blockers is used, sport cessation should be considered for as long as the arrhythmia persists, and until 1–2 half-lives of the antiarrhythmic drug used have elapsed.IIa--Isthmus ablation should be considered in competitive or leisuretime athletes with documented atrial flutter, especially when therapy with flecainide or propafenone is intended.IIa--Where appropriate, AF ablation should be considered to prevent recurrent AF in athletes.IIa--When a specific cause for AF is identified in an athlete (such as hyperthyroidism), it is not recommended to continue participation in competitive or leisure time sports until correction of the cause.III

Valvular heart disease

--OAC therapy (INR 2.0–3.0) is indicated in patients with mitral Stenosis, clinically significant mitral regurgitation, and AF (paroxysmal, persistent, or permanent).I--Percutaneous mitral balloon valvotomy should be considered for asymptomatic patients with moderate or severe mitral stenosis and suitable valve anatomy who have new-onset AF in the absence of LA thrombus.IIa--Early mitral valve surgery should be considered in severe mitral regurgitation, preserved LV function, and new-onset AF, even in the absence of symptoms, particularly when valve repair is feasible.IIa

DM

--AF patients with diabetes are recommended to undergo full assessment and management of allcardiovascular risk factors, including blood pressure, lipids, etc. I

Acute coronary syndrome

--DCC is recommended for patients with severe haemodynamic compromise or intractable ischaemia, or when adequate rate control cannot be achieved with pharmacological agents in patients with ACS and AF(I).--Intravenous administration of Amiodarone or BB is recommended to slow a rapid ventricular response to AF in patients with ACS, (CCB if no HF)(I).--Intravenous administration of digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with heart failure (IIb).

Pregnancy

--DCC can be performed safely at all stages of pregnancy, and is recommended in patients who are haemodynamically unstable due to AF, and whenever the risk of ongoing AF is considered high, for the mother or for the foetus.--Protection against thrombo-embolism is recommended throughout pregnancy in AF patients with a high thrombo-embolic risk.--Administration of an oral VKA is recommended from the second trimester, until 1 month before expected delivery.--Rate control BB or a non-dihydropyridine CCB should be considered. During the first trimester of pregnancy, the use of β-blockers must be weighed against the potential risk of negative foetal effects.--flecainide or ibutilide for rhythm control, digoxin for rate control IIb

NB. Warfarin+ pregnancy

--Teratogenic effects:-Potentially teratogenic (low MW, cross placenta) Embryopathy , spontaneous abortion and stillbirth.-The teratogenic effect appears to be dose related, with doses less than 5 mg/day providing the highest margin of safety {regardless of INR}-most common bone and cartilage nasal and limb hypoplasia--CNS abnormalities (including optic atrophy, microcephaly, mental retardation, spasticity, and hypotonia)-Immaturity of fetal enzyme systems and the relatively low concentration of vitamin K-dependent clotting factors render the fetus more sensitive than the mother to the anticoagulant effects of warfarin risk of hemorrhagic fetal death during vaginal delivery warfarin should be discontinued after 34 to 36 weeks of gestation -Preterm cesarean delivery may prevent hemorrhagic fetal death, and fresh frozen plasma should be administered to the neonate, mother

--UFH (c):-Relative difficulty of maintaining a stable therapeutic response, the inconvenience of parenteral administration, and the complications of heparin-induced thrombocytopenia and bone demineralization in patients treated for more than seven weeks-Guided by APTT--LMW heparin (B):-Sustained, stable therapeutic response-Reduce the inconvenience of parenteral administration-Laboratory monitoring of the anticoagulant effect of LMW heparin is generally not performed in nonpregnant patients, but some authors recommend measuring anti-factor Xa levels four hours after injection in pregnant patients-Less likely to precipitate heparin-associated thrombocytopenia, unclear whether bone loss may be significantly reduced-American College of Obstetricians and Gynecologists has stated that LMW heparin can be considered in women who are candidates for prophylactic or therapeutic anticoagulation during pregnancy- Patients should be switched to subcutaneous unfractionated heparin about two weeks prior to the expected delivery; this will permit regional anesthesia for labor {epidural haematoma}

Mechanical prosthetic heart valves:--FDA LMWH is not recommended for thromboprophylaxis in pregnant women with prosthetic heart valves.--However, other expert panels disagree, and the American College of Chest Physicians recommended that LMWH remain a therapeutic option in this setting

2008 ACCP Guidelines

One of three approaches for anticoagulation during pregnancy:

--Aggressive adjusted-dose unfractionated heparin throughout the pregnancy; heparin is administered subcutaneously every 12 hours in doses adjusted to keep the mid-interval aPTT at least twice control or to attain an anti-Xa level of 0.35 to 0.70 U/mL. After a stable dose is achieved, the aPTT should be measured at least weekly.--Adjusted-dose subcutaneous LMW heparin therapy throughout the pregnancy in doses adjusted according to weight to achieve the manufacturer's recommended anti-Xa level four hours after subcutaneous injection.--Unfractionated or LMW heparin therapy (as above) until the thirteenth week, a change to warfarin until the middle of the third trimester, and then restarting unfractionated or low molecular weight heparin until deliveryHeparin can be restarted 12 hours post-cesarean delivery and 6 hours post-vaginal birth, if no significant bleeding has occurred replaced with warfarin (stopping the heparin when the INR is therapeutic)

Postoperative AF

--Oral β-blockers are recommended to prevent post-operative AF for patients undergoing cardiac surgeryin the absence of contraindications(I)--Restoration of sinus rhythm by DCC is recommended in patients who develop post-operative AF and are haemodynamically unstable (I)--Pre-operative administration of amiodarone should be considered as prophylactic therapy for patients at high risk for post-operative AF (IIa)--Unless contraindicated, antithrombotic/anticoagulationmedication for post-operative AF should be considered when the duration of AF is >48 h—CV 4 weeks, more if high risk for stroke--Sotalol, steroids for prevention (IIb) as SE

Hyperthyroidism

--In patients with active thyroid disease, antithrombotic therapy is recommended based on the presence of other stroke risk factors.--Administration of a β-blocker is recommended to control the rate of ventricular response in patients with AF complicating thyrotoxicosis, unless contraindicated (CCB).--If a rhythm control strategy is desirable, it is necessary to normalize thyroid function prior to cardioversion, as otherwise the risk of relapse remains high.--Once a euthyroid state is restored, recommendations for antithrombotic prophylaxis are the same as for patients without hyperthyroidism.

Accessory pathway

--Catheter ablation of an overt AP in patients with AF is recommended to prevent SCD, and patients who survived SCD.--Catheter ablation is recommended for patients with high risk professions (e.g. pilots, public transport drivers).--Catheter ablation is recommended in patients at high risk of developing AF in the presence of an overt butasymptomatic AP on the surface ECG.

Hypertrophic cardiomyopathy

--Restoration of sinus rhythm by DCC or pharmacological cardioversion is recommended in patients with HCM presenting with recent-onset AF.--OAC therapy (INR 2.0–3.0) is recommended in patients with HCM who develop AF unless contraindicated.--Amiodarone (or alternatively, disopyramide plus β-blocker) should be considered in order to achieve rhythm control and to maintain sinus rhythm in patients with HCM--Catheter ablation of AF should be considered in patients withsymptomatic AF refractory to pharmacological control.--Ablation procedures (with concomitant septal myectomy ifindicated) may be considered

Pulmonary disease

--Correction of hypoxaemia and acidosis is recommended initial management for patients who develop AF during an acute pulmonary illness or exacerbation of chronic pulmonary disease.--DCC should be attempted in patients with pulmonary diseasewho become haemodynamically unstable as a consequence of AF.--A non-dihydropyridine calcium channel antagonist (diltiazem or verapamil) should be considered to control the ventricular rate in patients with obstructive pulmonary disease who develop AF (or B1 selective blocker in small dose).--Theophylline and β-adrenergic agonist agents are not recommended in patients with bronchospastic lung disease who develop AF.--Non-selective β-blockers, sotalol, propafenone, and adenosine arenot recommended in patients with obstructive lung disease whodevelop AF.

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