Atrial Fibrillation

A 60 year old male patient with a history of hypertension is

referred for assessment.
He informs you that he has been well except for a slight stroke
4 years ago but made a full recovery from same.
Apart from an irregular pulse there is no other relevant history
and he is not diabetic.
Clinical examination suggests atrial fibrillation which is
confirmed on ECG. Examination was otherwise normal. You
are aware of the relationship between atrial fibrillation and
stroke.
What are the treatment options for this man ?
Atrial Fibrillation

Ruth Barrett
Meena Grewal
Karen Whelan
 Atrial Fibrillation
• Atrial Fibrillation is a chaotic, irregular atrial rhythm at 300-
600 bpm
• the AV node responds intermittently, hence an irregular
ventricular rate.
• It occurs in 5-10% of patients >65.
• It also occurs, particularly in a paroxysmal form, in younger
patients.

Classification:
• Continuous
– Acute (≤ 48 hrs)
– Chronic
• Paroxysmal
 Causes
Cardiac causes:
• Ischaemic Heart Disease
• Hypertensive Heart Disease (LVH)
• Valvular Heart Disease (esp Mitral Stenosis)
• Pericarditis
• Cardiomyopathy, heart failure
Metabolic:
• Thyrotoxicosis
• Alcohol (acute or chronic)
Pulmonary
• Pulmonary Embolism
• Pneumonia
• COPD
• Cor Pulmonale
Other
• Idiopathic/ “lone AF”
• ↓K, ↓Mg
• Post-op
• Infection e.g UTI
Symptoms
• May be asymptomatic
• Chest pain
• Palpitations
• Dyspnoea
• Faintness
Signs
• Irregularly irregular pulse
• Signs of LVF
 Investigations
ECG
• Absent P waves
• Irregular QRS
complexes
 Investigations
• Look for an underlying cause
• U&Es
• Cardiac enzymes
• TFTs
• Consider ECHO to look for left atrial
enlargement, mitral valve disease, poor LV
function and other structural abnormalities
 Chronic AF

1. Rate or Rhythm control

2. Warfarin or Aspirin/Clopidogrel or
no anticoagulation
 Rate Control
Rate control is the first option if

• >65 years
• Coronary artery disease
• Unsuitable for cardioversion
» Anticoagulants contraindicated
» AF lasting longer than 1 year
» Mitral stenosis present
» Past attempts have failed
» An ongoing reversible cause (eg. Thyrotoxicosis)
 Rate control
1. Beta blocker
or
2. Rate limiting Ca channel blocker
-Verapamil / Diltiazem
If no effect - add
3. Digoxin

Rate control is as effective as rhythm control in decreasing

morbidity and mortality in most people with chronic AF.
 Beta Blocker
propranolol, metoprolol
C/I
2nd or 3rd degree heart block
unstable heart failure
asthma
Peripheral vascular disease (intrinsic sympathomimetic BB preferred)

Caution
Diabetes – masking of hypoglycaemia (cardioselective BB preferred)
COPD (c/i if exacerbation of COPD occurs)
Renal Failure patients – water soluble BB may accumulate (atenolol)

Other SE
impotence
sedation, sleep alteration
 Rate limiting CCB
Verapamil most cardioselective CCB.
Potent negative chronotropic and inotropic effects
Diltiazem cardio and vasculitic effects

C/I
Hypotension
2nd/3rd degree HB
Heart Failure

SE
Vasodilator effects – headache, flushing, dizziness.
Constipation
 Digoxin
C/I
WPW syndrome
HOCM
2nd degree Hb

SE
Cardiac- bradycardia, HB, arrythmias
Parasympathetic activity – n&v, diarrhoea, blurry yellow vision.
↑toxicity with – renal failure, hypokalemia, amiodarone, verapamil

Notes
Dose is individualised (+/- plasma monitoring)
Low dose for elderly/renal impairment.
Amiodarone and Verapamil increase digoxin levels
 Rhythm Control
Rhythm control is first choice if

• Younger patient
• Symptomatic
• CCF
• Px for first time with ‘lone AF’
• AF is secondary to a corrected precipitant
 Rhythm Control
DC Electrical Cardioversion
Pre-cardioversion echo
Pre treat x4 weeks with sotolol or amiodarone
if ↑risk failure (past failure or AF recurrence)

Pharmacological Cardioversion
• Flecainide if no structural heart disease
• IV amiodarone if structural heart disease
 Flecainide
Class 1C (Na+ channel blocker)
C/I
Heart Failure
Hx of MI
valvular disease

SE
dizziness
visual disturbances
 Amiodarone
Class 3 ( K+ channel blocker)
Monitor
• TFTS x6months
• LFTs x6months
• CXR and PFTs prior to initiation
SE
Hypo/hyperthyroidism
photosensitivity rashes
corneal microdeposits – dazzled by headlights
peripheral neuropathy and myopathy

Notes
long half-life. Use other antiarrythmics with caution in following 3 months.
Drug interactions – warfarin, digoxin, phenytoin.
Suspect pneumonitis if progresssive SOB occurs.
 Other options
• AV node ablation
• Pacemaker
• Pulmonary vein ablation

Notes on anti-arrythmics
• Negative inotropic effects tend to be additive
• Usually initiate on an inpatient basis
• Check QT interval on initiation
• ↓K+ enhances arrythmogenic effect of many drugs.
 Thromboprophylaxis
• Major complication of AF is thromboembolism
resulting in:

• Ischemic stroke (emboli to cerebral circulation) NOTE:

AF is an independent risk factor for stroke

• Systemic emboli to renal arteries, cornary arteries,

superior mesenteric artery , splenic or femoral arteries
 Anticoagulation
• Continous AF:
• Valvular AF : anticoagulate with warfarin (INR 2-3, for
mechanical valves INR 2.5-3.5)

• Non-valvular AF: whether or not to anticoagulate

depends on the risk of ischemic stroke which is
estimated with CHADS 2 score
 CHADS2 Score: Risk Assessment Tool

• C = Congestive Heart Failure (EF<35%) (1)

• H = Hypertension (systolic > 160mmHg) (1)
• A = Age > 75 years old (1)
• D = Diabetes (1)
• S = Prior cerebral ischemia (stroke or TIA) (2)

• Note: the higher the score, the higher the risk

of stroke
 How to interpret CHADS 2 score
• CHADS2 ≥ 2: treat with warfarin (INR 2-3)
• unless contraindicated or annual major bleeding risk exceeds
3%

• CHADS2= 1: treat with aspirin or warfarin

• can perform ECHO and if underlying structural abnormality,
use warfarin

• CHADS2 = 0: treat with aspirin

• 81-325 mg daily or if warfarin is contraindicated
 Contraindications to Warfarin use
• Bleeding diathesis
• Platelets < 50 x 109/L
• BP>160/90 (consistently raised)
• Renal impairment
– Creatine clearance< 10ml/min

• Peptic ulcer disease

• Pregnancy
• Bacterial endocarditis
• Caution: Hepatic or Renal disease, recent surgery,
patient factors – falls risks, compliance issues
 Side Effects of Warfarin Use
• Haemorrhage (INR monitoring essential)
• Hypersensitivity reactions, rash
• Alopecia
• Skin necrosis
• Jaundice
• Hepatic dysfunction
• Gastrointestinal disturbance
• Drug interactions: beware prn NSAID use:
» many drugs interact, check appendix in BNF and monitor INR closely after any changes in drug
therapy

• Intercurrent illness, dietary changes, changes in alcohol intake (alcohol

potentiates the effect of warfarin), or high green vegetable intake, may
alter warfarin requirements
 Note on Clopidogrel
• If patients are aspirin intolerant, clopidogrel may be used

• Clopidogrel is contraindicated in:

– Active pathological bleeding, especially GI or intracranial
– Severe liver impairment
– Pregnancy and breastfeeding

• Side effects:
risk of bleeding
GI upset

• Note: when compared to warfarin, aspirin and clopidogrel together are not
superior in preventing ischemic stroke
 No Thromboprophylaxis
• If stable sinus rhythm has been restored
• No risk factors for emboli
• AF recurrence unlikely (i.e. no failed
cardioversions, no structural heart disease, no
previous recurrences, and no sustained AF for
>1 year)
 Acute AF
• Acute AF (<48 hours since onset):
– If hemodynamically unstable , resusitate and try emergency
cardioversion
– If hemodynamically stable, rate control, then therapeutic
anticoagulation and cardioversion
– if >48 hours since onset and undergoing either electrical or drug
cardioversion, there is a risk of thromboembolism from the left
atrium or left atrial appendage
– therefore, anticoagulate with warfarin at least 3 weeks prior
and 4 -6 weeks after cardioversion. However, if 48hour time
period has elapsed, cardioversion without anticoagulation is
okay if trans-oesophageal echo shows no intracardiac thrombus.
Acute AF

Chest 2009;135;849-859
 Paroxysmal AF
(NICE 2006)
• “Pill in the Pocket”
• Flecainide PRN – may be tried if:
-infrequent AF
- BP >100 systolic
- no past LV dysfunction
• If this fails, try regular Beta Blocker
• Anticoagulate (Aspirin/Warfarin)
 Summary
1. Treat any reversible cause
2. Control ventricular rate
3. Consider cardioversion
4. Prevent emboli AF

Continuous Paroxysmal
 References

• Oxford handbook pages 116-117

• European Journal of Internal Medicine 20 (2009)
672-681, Review article: Atrial Fibrillation:
Mechanistic insights and treatment options
• Blood Reviews 23 (2009) 241-244: Atrial
Fibrillation and Coagulation: who and when?
• Chest 2009;135;849-859: Acute Management of
Atrial Fibrillation
• St James Prescriber’s guide 2009