AF GUIDELINES

DR.ANKIT JAIN

A

AF—Classification

MECHANISM OF AF

Risk Factors and Biomarkers for AF

Clinical evaluation

Investigations

• All patients with AF should have a 2D ECHO to detect underlying structural heart disease, assess cardiac function, and evaluate atrial size

• Laboratory evaluation Electrolytes, thyroid, renal, and hepatic function, and a blood count

TEE

• TEE is the most sensitive and specific technique to detect LA

• Can be used to guide the timing o cardioversion or catheter ablation procedures

• Can identify features with an increased risk of LA thrombus formation Reduced LAA flow velocity, spontaneous LA contrast

Risk Stratification Schemes (CHADS2, CHA2DS2-VASc, and HAS-BLED)1. CHADS2 CHF, HTN , Age ≥75 years, DM, Prior Stroke or

TIA or Embolism

2. CHA2DS2-VASc CHF, HTN, Age ≥75 years (doubled), DM, Prior Stroke or TIA or Embolism (doubled), Vascular disease, Age 65 to74 years, Sex category

LIMITATIONS

• limitation of the CHADS2 score is that a CHADS2 score of 1 is considered an “intermediate” risk and those at lowest risk may not be well identified

• CHA2DS2-VASc index better discriminated stroke risk among subjects with a baseline CHADS2 score of 0 to 1 with an improved predictive ability

BLEEDING SCORE

• HAS-BLED • HTN (SBP>160 mmHg), abnormal liver or renal

function, history of stroke or bleeding, labile INRs, elderly age (age >65 years), drugs that promote bleeding, or excess alcohol

• Score of ≥3 indicates potentially “high risk” for bleeding

STROKE RISK

Risk-Based Antithrombotic Therapy: Recommendations

Risk-Based Antithrombotic Therapy: Recommendations

Cardiac Surgery—LAA Occlusion/Excision

Class IIb• Surgical excision of the LAA may be considered in

patients undergoing cardiac surgery

Rate Control: Recommendations

• The optimal heart rate targets for rate control are controversial

• The target used in trials were resting heart rate of either ≤80 bpm or averaging ≤100 bpm on ambulatory monitoring

• Without a rate >100% of the maximum age-adjusted predicted exercise heart rate

Rate Control: Recommendations

Rate Control: Recommendations

Rhythm Control

• Persistent symptoms associated with AF is the most compelling indication for a rhythm-control strategy

• Difficulty in achieving adequate rate control• Younger age• Tachycardia-mediated cardiomyopathy• First episode of AF, AF that is precipitated by an acute illness,

and patient preference• AF progresses from paroxysmal to persistent and

subsequently results in electrical and structural remodeling that becomes irreversible with time

Thromboembolism prevention

TEE

• TEE guidance is an alternative to 3 weeks of anticoagulation prior to cardioversion

• Therapeutic anticoagulation is achieved, followed by a TEE; if no thrombus is seen (including in the LAA), cardioversion is performed and anticoagulation is continued for a ≥4 weeks

Thromboembolism prevention

Direct-current Cardioversion

C/I

• Elective cardioversion should not be performed in patients with

• Digoxin toxicity• Severe hypokalemia

PHARMECOLOGICAL CARDIOVERSION

• Drugs are effective when initiated within 7 days after the onset of an episode of AF

• In recent onset AF IV ibutilide restored sinus rhythm in about 50% of patients with an average conversion time of <30 minutes

• The rates of success were higher in those patients with atrial flutter than in those with AF

CONTD..

• The major risk is excessive QT prolongation,• Polymorphic ventricular tachycardia, in up to 3%- 4%

patients.• ECG monitoring should be continued for ≥4 hours after

administration• Ibutilide should be avoided in patients with QT prolongation,

marked hypokalemia, or a very low ejection fraction (EF) (<30%)

CONTD..

• An oral dose of flecainide or propafenone can be used as a “pill-in-the-pocket”

• Termination of AF may be associated with bradycardia owing to sinus node depression Initial conversion trial should be done in hospital

• A beta blocker or CCB should be administered ≥30 minutes before administering IC agent to prevent a rapid ventricular response During flutter

Pharmacological cardioversion

DRUG DOSE

Drugs for Preventing AF and Maintaining Sinus Rhythm

• Before antiarrhythmic drug treatment is initiated, reversible precipitants of AF should be identified and corrected

• After the first episode of AF that resolves, it is reasonable to address the underlying causes of AF and to not initiate antiarrhythmic drug treatment until AF recurred

CONTD..

• Decisions regarding anticoagulation should be based on the patient’s individual stroke risk profile and not on the response to antiarrhythmic drug therapy

• Antiarrhythmic drug efficacy is modest and asymptomatic AF recurrences are common

• So a rhythm-control strategy should not result in cessation of antithrombotic therapy, rate control therapy, or treatment of underlying heart disease

CLASS 1

• 1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended

• 2. The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm Amiodarone , Dofetilide , Dronedarone , Flecainide ,Propafenone ,Sotalol

• 3. Due to toxicites amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated

Class IIa

• A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardia-induced cardiomyopathy

Class III: Harm

• 1. Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent

• 2. Dronedarone should not be used for treatment of AF in patients with New York Heart Association (NYHA) class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks

DRUGS FOR RHYTHM CONTROL

Primary prevention of AFwith “upstream” therapy

AF Catheter Ablation to Maintain Sinus Rhythm

• Class I

1) AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired ( (Level of Evidence: A)

2) Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended

CLASS IIA

• AF catheter ablation is reasonable for selected patients with

symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication (Level ofEvidence:A)

CLASS IIB

1. AF catheter ablation may be considered for symptomatic

long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired (Level of Evidence: B)

Class III: Harm

1. AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C)

2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C)

Surgery Maze Procedures: Recommendations

Class IIaAn AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications. (Level of Evidence: C)

Class IIbA stand-alone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches

Summary of Recommendations for Specific Patient Groups and AF

Hypertrophic cardiomyopathy

AF complicating ACS

WPW and pre-excitation syndromes

HEART FALIURE

Post cardiothoracic surgery

CONTD..

THANK YOU