=====Atrial FIB===== Result of chaotic atrial depolarisation from multiple areas of re-entry within the atria > irregularly irregular rhythm without discreet P waves. *Ischaemic Heart disease - 50% *Valvular disease *Hypertension *electrolyte disturbance – hypokalaemia, hypomagnesaemia *Toxicity – thyrotoxicosis, alcohol *other May present with palpitations, syncope, may be hypotensive ===Classification=== ^First diagnosed |AF not formally diagnosed before | ^Paroxysmal |terminates spontaneously or with intervention within 7/7 of onset. | ^Persistent |continuous beyond 7/7 | ^Long-standing persistent |Continuous >12/12 | ^Permanent |No further attempts to restore/maintain sinus rhythm will be undertaken. | Proposed classification: *4S-AF scheme has 4 domains and may provide a framework for prognostic evaluation -Stroke risk -Symptom severity -Severity of AF burden -Substrate severity ====Diagnostic workup==== [{{:wiki:cardiovascular:esc_af.png?500|//**2020 ESC AF Workup**//}}] ===1. Stroke risk=== *apixaban, dabigatran, edoxaban, and rivaroxaban have shown non-inferiority to warfarin in the prevention of stroke/systemic embolism. *NOACs were associated with a 19% significant stroke/systemic embolism risk reduction, *51% reduction in haemorrhagic stroke, and similar ischaemic stroke risk reduction compared with VKAs, *NOACs were associated with a significant 10% reduction in all-cause mortality *In the ACTIVE W (Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events) trial, dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was less effective than warfarin for prevention of stroke, systemic embolism, myocardial infarction, and vascular death (the annual risk of events was 5.6% vs. 3.9%, P =0.0003), with a similar rate of major bleeding {{:wiki:cardiovascular:af_anticoag_abc.png?400|}} ===2. Symptom severity=== Based on 6 symptoms, affect on daily activity is assessed: *palpitations *fatigue *dizziness *dyspnoea *chest pain *anxiety during AF ^Score ^Symptoms ^Description (EHRA symptoms)| ^1 ^None |AF does not cause any symptoms | ^2a ^Mild |Normal daily activity not affected by symptoms related to AF | ^2b ^Moderate |Normal daily activity not affected by symptoms related to AF, but patient troubled by symptoms | ^3 ^Severe |Normal daily activity affected by symptoms related to AF | ^4 ^Disabling |Normal daily activity discontinued | ===3. AF burden=== *the overall time spent in AF for a given period [[https://academic.oup.com/cardiovascres/article/117/7/1/6258174|Oxford academic review 2021]] *atrial high-rate episodes (AHREs) or subclinical AF lasting ≥5–6min are associated with both an increased risk of subsequent onset of clinical AF and an increased risk of stroke/thromboembolism which may be non-linear. <5min have ~1/2 the risk ===4. Substrate severity=== |• relates to LA dilation and fibrosis\\ • implies subsequent LA dysfunction & delay in electromechanical conduction. |{{:wiki:cardiovascular:af_substrate.png?500|}} | ====Management==== Aim of Treatment: – alleviate symptoms and prevent complications esp stroke Treatment options: anticoagulation, rate control, rhythm control (DC reversion, ablation, chemical) Randomized clinical trials on AF have shown no influence on survival, stroke or heart failure with rhythm control using antiarrhythmic drugs and/or cardioversions for paroxysmal or persistent AF ^//Action// ^ //Agent// ^ //Notes// ^ ^Rate (First Line) |ẞ blocker or\\ Ca channel blocker or\\ digoxin |//**persistent AF, >65yo, patients who have coronary art disease, contra-indications to anti-arrhythmic agents, no Hx cardiac failure.**//\\ IV Metoprolol (ẞ1 selective) 2.5-5mg over 2mins (Labetalol, propranolol=non-selective ẞ)\\ Verapamil (5-10mg0 or diltiazem (0.25mg/kg)\\ //**Digoxin if non-paroxysmal AF and if sedentary**//\\ Magnesium has modest effective\\ Clonidine – possibly has similar effectiveness to Verapamil and Digoxin\\ NOT Sotalol – pro-arrhythmic and tendency to TdP | ^Rhythm |Flecainide\\ Amiodarone\\ Dronedarone |symptomatic, <65yo, new onset AF, secondary AF when cause has been treated, patients with CCF\\ Flecainide – if no structural or IHD\\ Amiodarone – for pts with LVF\\ Dronedarone – long term after DC reversion | | |Synchronised DC reversion |Unstable patients or failed anti-arrhythmic Rx\\ sedation + 50J followed by 100-200J if fails. | | |L atrial ablation |Paroxysmal AF, symptomatic persistent AF with drug failure or if anticoag contra-indicated or not tolerated | **Anticoagulation**(Quick View)<@anno:[16;;anno_dylan]>{{:wiki:haematology:anticoagulants}} *Apixaban – with non-valvular AF with ≥1 risk factors *Dabigatran etexilate *Rivaroxaban *Vit K antagonist – warfarin for patients with mechanical valves *Antiplatelets agents – not aspirin monotherapy Bleeding and stroke risks *CHA2DS2-VASc score for stroke risk *HAS-BLED for bleeding risk ====ABC Management approach==== ^A - Anticoagulation/Avoid stroke |overall, AF increases stroke risk 5x\\ assess stroke risk: CHA2DS2-VASc score\\ before anti-coag Rx, assess bleeding risk: HAS-BLED score | ^B - Better Symptom Mx | | ^C - CVS and comorbidity optimisation|| ====ED Management==== {{ :wiki:cardiovascular:af_guideline_575fm.pdf |}} ====HAS-BLED score==== ^ ^ HAS-BLED score^| ^ ^ Condition ^ Points| ^H |Hypertension: (uncontrolled, sBP≥160mmHg) ^ 1 | ^A |Abnormal renal or liver function:\\ •Dialysis, transplant, Cr >200 µmol/L\\ •Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal ^\\ 1 \\ 1 | ^S |Stroke: Prior history of stroke ^ 1 | ^B |Bleeding: Prior Major Bleeding or Predisposition to Bleeding ^ 1 | ^L |Labile INR: (Unstable/high INR), Time in Therapeutic Range < 60% ^ 1 | ^E |Elderly: Age > 65 years ^ 1 | ^D |Drug or Alcohol History (≥ 8 drinks/week)\\ Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs) ^ 1\\ 1 | ====CHA2DS2-VASc score==== ^ ^CHA2DS2-VASc score^| ^ ^Condition ^Points | ^C |Congestive heart failure (or Left ventricular systolic dysfunction) ^1 | ^H |Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) ^1 | ^A2 |Age ≥75 years ^2 | ^D |Diabetes Mellitus ^1 | ^S2 |Prior Stroke or TIA or thromboembolism ^2 | ^V |Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)^1 | ^A |Age 65–74 years ^1 | ^Sc |Sex category (i.e. female sex) ^1 | ^^^ | |//**Mode of action of ẞ blockers in HT is not understood but do reduce CO, alter baroceptor sensitivity and block periph adrenoceptors**//\\ //**Some block renin secretion**//\\ //**Interfere with metabolic and autonomic response to hypoglycaemia**// | |**Metoprolol** |More ẞ1 specific (safer in asthma) | |**Labetalol** |Arteriolar vasodilator action. Non-selective ẞ | |**Propanolol** |additional effect of blocking the peripheral conversion of inactive T4 to active form T3.\\ Non-selective ẞ | |**Sotalol** |Water sol. Less likely to enter brain.\\ Additional class III anti-arrhythmic action.\\ Pro-arrhythmic and tendency to TdP | |**Atenolol** |Water sol. Less likely to enter brain.\\ Long duration action.\\ More ẞ1 specific | |**Bisoprolol** |Long duration action. More ẞ1 specific | |**Verapamil** |Not in WPW | |**Diltiazem** |Not in WPW | |**Flecainide** | | |**Amiodarone** | | |**Digoxin** |Not in WPW.\\ 0.5mg oral (no better IV) then 0.25mg per 6/24 to total 1.5mg | ==References include:== [[https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa612/5899003#207821183|Euro Heart J: 2020 ESC AF guidelines]]\\