heterogeneity of af not all af are the same!!!!!!
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Heterogeneity Of AF Not all AF are the same!!!!!!. Dr.Mervat Aboulmaaty Prof. of cardiology Ain Shams university 2008. Heterogeneity Of AF Not all AF are the same!!!!!!. - PowerPoint PPT PresentationTRANSCRIPT
Heterogeneity Of AFNot all AF are the same!!!!!!
Dr.Mervat Aboulmaaty Prof. of cardiology Ain Shams university 2008
Heterogeneity Of AFNot all AF are the same!!!!!!
Heterogeneity Of AFNot all AF are the same!!!!!!
AF with fast vent response & aberrancy
AF with controlled vent. response
AF WITH LBBB
AF with IVCD
AF regular because of VT
Atrial Flutter/AF
AF and AT Flutter
AF WITH SLOW VR
AF with CHB
AF with WPW syndrome
AF with WPW syndromeAF degenerating to VF
AF in Patient with CHF and CRT
AT Flutter and 1:1 conduction
After CV A-Pacing Native Conduction
AF HeterogeneityPrevalenceAF prevalence doubling with each
decade◦0.55 at age 50-59 years◦ 9% at age 80-89 years
3-fold increase in men New onset AF: men are 1. 5
times as likely as women to develop it
Incidence of AF in Men and Women
Associated conditions with AFReversible Causes of Atrial
Fibrillationalcohol intake (“holiday heart
syndrome”), surgery, electrocution,MI, pericarditis, myocarditis, PE, pulmonary diseases, hyperthyroidism with Atrial flutter, WPW,AVNRT, AVRT complication of cardiac or thoracic
surgery
Associated conditions with AFAcute and chronic coronary
diseaseHTN Hypertrophic ,dilated &
restrictive CM ASDValvular Rheumatic 40% MS 75% MR
Cardiac conditions increasing the risk of AF
Men Women
20% 31%
HF 4.5% 5.9%
Valve disease 1.8% 3.4 %
Myocardial infarction
40% 20%
Atrial Fibrillation Without Associated Heart Disease lone AFLone AF before age 60 yrs without HTN or
overt structural HD (clinical exam, ECG and echo)
30% to 45% of paroxysmal AF and 20% to 25% of persistent AF occur in
younger patients without underlying diseaseAF can present as an isolated or familial
arrhythmiaIn elderly,
◦ myocardial stiffness may be associated with AF, ◦ Heart disease may be coincidental and unrelated
to AF.
AF and autonomic influenceVagal predominance in the minutes
preceding the onset of AFVagally mediated AF occurs at night or after
meals Cholinergic agents such as disopyramide
are helpful to prevent recurrent vagally
mediated AF Adrenergically induced AF occurs during daytime in pts with organic HDBeta blockers for adrenergically induced AF
Autosomal dominant hereditary AF Mapping analysis of the AF family
ECG and missense mutation
DNA and amino acid sequence of KCNQ1 missense mutation associated with affected members in the AF family. DNA sequence analysis revealed an A to G substitution causing an S140G mutation in the S1 segment of KCNQ1.
AF family with an autosomal recessive inheritance pattern
AF in the family manifests with early onset at fetal stage and is associated with neonatal sudden death
Some cases ventricular tachyarrhythmias and cardiomyopathy.
Heterozygous carriers have significant prolongation of P-wave duration compared with non-carriers
The maximum multipoint LOD score of 4.10 was obtained for 4 markers: D5S426, D5S493, D5S455, and D5S1998.
Circulation. 2004;110:3753-3759
Genetic map with chromosome 5p13 markers and locationof putative arAF1 gene
Patterns of AF
Mechanisms of AF
Rapidly firing atr automatic foci PV triggersAnatomical substrate for reentry within the PV
Symptoms of AFEmbolic complicationExacerbation of HFPalpitations, chest pain, dyspnea,
fatigue, lightheadednessSyncope.
◦upon conversion in patients with SSS◦ rapid ventricular rates in patients with HCM,
AS, WPW Polyuria with the release of ANP as
episodes of AF begin or terminate. Tachycardia-mediated cardiomyopathy
Pharmacological and non pharmacological Treatment
Drugs and ablation are effective for both rate and rhythm control
Ryhtm control vs Rate control For rhythm control, drugs are typically the first
choice and LA ablation is a second-line choice ( symptomatic lone AF young pts , no structrual HD)
RF ablation for WPW, AVRT, Atrial FlutterRF ablation in association with cardiac surgery
face a unique opportunity during MV Replacement, LAA obliteration
Standalone Surgical procedure (maze III or LA ablation)
Oral, H. et al. N Engl J Med 2006;354:934-941
Circumferential Pulmonary-Vein AblationRF Pulmonary Vein Isolation
“Ablate and pace” strategy that often yields remarkable symptomatic relief ( the negative effect of long-term RV) BIV Pacing
Atrial pacing, either in RA alone or Biatrial to prevent recurrent paroxysmal AF in pts with Bradycardic indication for Pacing (SSS AAI vs VVI)
Atrial pacing IS Not a primary therapy for prevention of AF
Atrial defibrillators for patients with LV dysfunction who are candidates
for implantable ventricular defibrillators
Pharmacological and Non-Pharmacological Treatment
Mortality and Morbidity with AFDeathAF Increases Mortality with AMIAF Increases mortality 50% Men 90% WomenHighest death 1st yr after AF diagnosisStrokeRisk 35% 1.5% at age 50-59 y23.5% at age 80-89AF+HF+CAD increase risk of a stroke 2
fold
Risk of StrokeCHADS2 Risk Criteria Score
◦Prior stroke or TIA 2◦Age 75 y 1◦Hypertension 1◦Diabetes mellitus 1◦Heart failure I
aspirin (325 mg) associated with 44% stroke rate reduction
Warfarin 50% more effective than aspirin for prevention of ischemic stroke
Thank youعليكم السالم
AF in Patient with CHF and CRT
General schema representing AF mechanisms
Predictors of AFHTN and DM were significant
independent predictors of AF increasing the risk 1.5 fold. (Framingham Study)
HTN is responsible for more AF (14%) than any other risk factor
Predictors of AFIndependent ECHO predictors of AF :
◦LA enlargement, ( 5mm AF 39%)
◦LV fractional short. ( 5% AF 34%)
◦LV wall thickness ( 4mm AF 24%)
ECG evidence of:◦ LVH was also a powerful age adjusted
predictor
Mortality results
0
5
10
15
20
25
Cum
ulat
ive
mor
talit
y (%
)
Year 1 Year 2 Year 3 Year 4 Year 5
Rhythm control Rate control
N Engl J Med 2002;347:1825-33.