1
AF: Issues with Anticoagulation
•AFL: Anticoagulation like AF
•When undergoing procedures with risk for bleeding :
May DC warfarin for up to one week without substituting heparin except for high risk pts. (Prosthetic valves, prior
stroke or TIA). Class IIa (c)
•The use of low molecular heparin in AF has become common practice but it is based on extrapolation from
DVT studies and from observational studies (no sufficient data )
2
AF: Issues with Cardioversion
•AF duration unknown or over 48 hours : AC for 3 weeks before and one month after CV
•Risk for strokes is same for chemical or electrical CV
•TEE to rule out thrombus before CV is reasonable. (Class IIa, level of evidence A)
AF: Rate Control•60 – 80 bpm at rest, 90 – 115 with moderate exercise.
•AVN blocking agents (BB, CA channel blockers, Digoxin)
•Digoxin reduces only resting heart rate and not during activity
•Amiodarone can be used for rate control when others fail (severe LV dysfunction and CHF)
•AV junction ablation and PPM only as a last resort
3
AF: Rhythm Control
4
Antiarrhythmic Drug therapy:• Class Ia (Quinidine, Procainamide)
Claa Ic (Flecainide, Propafenon) Class III (Sotalol, Amiodarone,
Dofetilide) • Limited efficacy• Significant side effects• Pro-arrhythmic effects• Increase mortality
New AADs: Forget it………
AF: Newer Class III AA DrugsDofetilide
•Introduced in 1999. Oral agent. Prolongs APD by blocking Ikr.
•More effective than low dose sotalol in restoring SR
•Has neutral effect on mortality in HF and post MI patients.
•Prolongs QT interval and may cause Torsades de Points in 3-5 %
of patients (dose adjusted according to creatinine clearance)
Ibutilide•Introduced in 1996. An injectable
agent (1-2mg)
•Prolongs APD by enhancing a slow inward NA current
•50% success in termination of acute AF (higher success rates for
AFL
•May cause Torsades de Points in up to 8% of patients
5
AF: Rate vs. Rhythm ControlWould a strategy of rhythm control results in:
•Less ischemic strokes?
•Improved symptoms?
•Better quality of live?
•Survival benefit?6
