Atrial Fibrillation….Atrial Fibrillation….

Robert Minera D.O. PGY-IVARMC Emergency Medicine

Atrial Fibrillation….Atrial Fibrillation….aka Pennington aka Pennington

SyndromeSyndromeRobert Minera D.O. PGY-IVARMC Emergency Medicine

EpidemiologyEpidemiology

• Most frequently diagnosed arrhythmia • Affects 2.3 million people in the US• Affects 1/136 people in the US• Incidence increases with age • 8% of people >80 yrs. old

Signs and SymptomsSigns and Symptoms

• Palpitations• Weakness• Dizziness• Reduced exercise capacity• Dyspnea• Asymptomatic

Etiology/Risk FactorsEtiology/Risk Factors• Structural heart disease• Chronic lung disease• Pneumonia• Hyperthyroidism• Alcohol use• Pulmonary embolism• HTN• Pericarditis

Differential DiagnosisDifferential Diagnosis

• Narrow Complex Tachycardias– Atrial Fibrillation– Atrial Flutter– AVNRT– AVRT– Atrial tachycardia– Sinus tachycardia– Multifocal atrial tachycardia

SVT is a category, not a diagnosis!

ACC/AHA/ESCACC/AHA/ESC

• Paroxysmal: terminates in < 7 days

• Persistent: fails to terminate within 7 days

• Permanent: > 1 year• Lone: Individuals without structural

heart disease, < 60 yrs old

Diagnostic Testing: EKGDiagnostic Testing: EKG

Narrow Complex

Irregularly Irregular

Rapid Ventricular Rate

Diagnostic Testing: TTEDiagnostic Testing: TTE

• To assess for structural heart disease– EF– Wall motion– Dilation/Hypertrophy– Size of right and left atrium– Valvular disease– Pericardial disease

Chest X-RayChest X-Ray

• Look for emphysema/COPD• Cardiac borders• Pneumonia

ManagementManagement

• Rate Control• Rhythm Control• Anticoagulation• Unstable patients

Rate ControlRate Control

• Why is rate control important?– Ischemia, MI, hypotension can occur– Long term: Cardiomyopathy

• Goals– Rest HR < 80 bpm– 24 Hour (Tele/Holter) < 100 bpm average– HR < 110 in 6 minute walk

Rate Control (con’t)Rate Control (con’t)

• Medications– Metoprolol / Esmolol: IV or Oral– Diltiazem: IV or Oral– Verapamil: Oral Only– Digoxin: Patients with hypotension– Amiodarone: Also for rhythm control

Rhythm ControlRhythm Control

• Indications– Symptoms of a-fib persistent– To avoid long term anticoagulation– Bleeding risk

Rhythm Control (con’t)Rhythm Control (con’t)

• Synchronized DC cardioversion– Emergencies/Hemodynamic instability– Greater efficacy than medications

• Pharmacologic cardioversion– If AF < 7days – dofetilide, flecainide,

ibutilide, propaferone or amiodarone– If AF > 7 day – dofetilide or amiodarone

Rate or Rhythm Control?Rate or Rhythm Control?

• AFFIRM Study: Rate versus rhythm control– No difference in incidence of stroke– Trend towards lower mortality in the rate

control group– This is STILL a controversial topic!– New study focusing on rhythm

conversion-Ottawa Protocol

Anticoagulation and Anticoagulation and CardioversionCardioversion

• Afib < 48 hours: – Cardioversion (CV)– No anticoagulation

indicated

• Afib > 48 hours: – Anticoagulate for

3-4 weeks before CV

– OR get TEE

– Anticoagulate for 1 month after CV

Anticoagulation – Long Anticoagulation – Long TermTerm

• Risk of CVA determined by CHADS2 score (CHF, HTN, >75, DM, Previous CVA x 2)

Score Annual Stroke Risk %

0 1.9

1 2.8

2 4.0

3 5.9

4 8.5

5 12.5

6 18.2

Key PointsMost patients, can wait

48 hours before starting

0-1 probably don’t need anticoagulation

5-6 should be bridged with heparin/LMWH

Management – UnstableManagement – Unstable

Unstable: A-fib associated with Hypotension

Synchronized electric Cardioversion immediately

Key PointsKey Points

• MI is a rare CAUSE of a-fib• Rate control must be achieved

during exercise, not just at rest• Not every patients needs to bridge

with heparin• Unstable patients should

immediately be cardioverted