shared:cards:atrial_fibrillation
Table of Contents
Atrial Fibrillation
Categorization
- Paroxysmal
- Persistent: greater than 7 days
- Long-standing persistent: more than a year
- Permanent: no longer trying to restor NSR
- Valvular: moderate to severe` MS or mechanical valve
Evaluation
- EKG: irregulary irregular without distinct p waves
- TTE: chamber sizes, valve disease, LVH, pericardial disease
- Labs: TFT, basic labs
- Exercise stress testing if s/s of ischemic heart disease
- Cardiac monitoring if suspicion for intermittent not captured on telemetry (e.g. cryptogenic stroke)
Cardioversion
- Immediate synchronized cardioversion
- Evidence of hypoperusion or shock
- Active ischemia
- Manifestations of severe HF
- Hypotension (thought to be due to AF)
- At least 4 weeks of anticoagulation ASAP s/p cardioversion
Anticoagulation
- No cardioversion planned: based on CHA2DS2-Vasc
- Cardioversion planned:
- Less than 48 hours, ASAP
- More than 48 hours or unknown, for 3 weeks prior to cardioversion
- TTE cardioversion: evaluate for thrombus, if negative, can immediately cardiovert
- Minimum of 4 weeks post cardioversion
- Regardless of rate vs. rhythm control, classification of AF
- DOACs > warfarin if eligible
- Warfarin recommended in valvular AF regardless of CHA2DS2-Vasc
- Renal adjustment:
- CKD 5 or ESRD: warfarin or apixaban
- Other NOACs can be adjusted based on CrCl
Rate Control
- Usually before attempts to restore NSR
- Usually BB (MTP, esmolol) and non-DHPR CCB (dilitiazem, verapamil)
- CCB avoided in LV dysfunction
- Both avoided if evidence of pre-excitation (procainamide)
- digoxin (not first line)
- amiodarone (not first line)
Rhythm Control
- Preferred when:
- Failure of rate control
- Heart failure
- Younger patients
- Early in natural history of AF (non-dilated LA, reversible cause, no HTN)
- Pharmacologic:
- Flecainde (without structural disease)
- Propafenone (without structural disease)
- Ibutilide (IV only, risk of QT prolongation)
- Dofetilide (maintenance)
- Amiodarone (structural heart disease, but numerous SEs)
- Sotalolol
- Non-pharmacologic
- Catheter ablation: symptomatic despite other interventions
- Surgical MAZE: usually when undergoing cardiac surgery for another reason
Stroke Prevention
- Watchman device (percutaneous LA appendage occlusion)
- SUrgical occlusion of LA appendage
AF and ACS
- Stable ACAD: usually single agent anticoagulant
- ACS with PCI:
- consider double therapy (oral anticoagulant and P2Y12 inhibitor)
- if triple therapy, consider transition to double therapy at 4-6 weeks
Medications
| Preferred antiarrhythmics in patients with AF | |
|---|---|
| No CAD or structural disease | Flecainide Propafenone |
| LVH | Dronedarone Amiodarone |
| CAD without heart failure | Sotalol Dronedarone |
| Heart failure | Amiodarone Dofetilide |
| Recurrent AF refractory to meds | Radiofrequency ablation |
shared/cards/atrial_fibrillation.txt · Last modified: 2020/07/01 00:16 by 127.0.0.1