Controversies in Atrial Fibrillation and HF Dr.Yahya Al Hebaishi Cardiac electrophysiology division, PSCC, Riyadh
Atrial Fibrillation: Rate or Rhythm? HF and AF: the twin epidemic of cardiovascular disease. Stroke prevention first and always? Rate or rhythm control in HF patients? AF ablation or AAT? Issue with device therapy in AF patients. Summary
AF :Treatment Strategies Rate control Maintenance of SR Stroke prevention Pharmacologic Ca 2+ blockers -blockers Digitalis Amiodarone Nonpharmacologic Ablate and pace Pharmacologic Class IA Class IC Class III -blocker Nonpharmacologic Catheter ablation Surgery (MAZE) Pacing Pharmacologic Warfarin Thrombin inhibitor Aspirin Nonpharmacologic Removal / isolation LA appendage Prevent remodeling ACE-I ARB Adapted from Prystowsky, Am J Cardiol. 2000;85:3D-11D.
Atrial Fibrillation: Stroke prevention?
Atrial Fibrillation: Rate or Rhythm?
AF management: stroke prevention CHA2DS2-VASc score Lip GY, et al., Chest 137, 263-272, 2010
AF management: bleeding risk HAS-BLED Score
LAA closure devices
Favours Rate Control Favours Rhythm Control Persistent AF Paroxysmal AF Newly Detected AF Less Symptomatic More Symptomatic >65 years of age < 65 years of age Hypertension No Hypertension No History of Congestive Heart Failure Congestive Heart Failure clearly exacerbated by AF Previous Antiarrhythmic Drug Failure No Previous Antiarrhythmic Drug Failure
Maintenance of SR in recurrent paroxysmal or persistent AF
A young lady with AF 44 -Year- old female with non ischemic cardiomyopathy for 3 years. Presented to ER with palpitation and heart failure symptoms for 2 days. No chest pain, syncope or presyncope No DM, HTN or Dyslipidemia No previous stroke or TIAs
A young lady with AF Rx include: ACEI and B-blocker on target doses in addition to Lasix 40mg daily, Aldactone 25mg daily. Has been complaint with Rx and diet.
A young lady with AF Physical examination: High JVP, irregular rapid pulse and bilateral cripitation. ECG showed A. fib with heart rate around 115/min. Echocardiogram: EF 40%, LA size 4.2 cm, mild MR, upper mild TR. Lab testes including TSH were unremarkable
A young lady with AF Patient received iv diuretics with modest improvement in her symptoms. Admitted to the hospital for further management.
A young lady with AF The most appropriate next step for stroke prevention in this patient: ASA 81mg daily No therapy ASA 325mg daily NOAC
A young lady with AF The most appropriate initial therapy in this patient AF: Sotalol 160mg twice daily Immediate CV Flecainide (pill-in-the pocket approach) AF ablation TEE guided CV Digoxin and Verapamil for rate control AV nodal ablation and Biv pacing.
A young lady with AF Patient had successful TEE guided CV with improvement in her symptoms. Started on Amiodarone therapy for maintenance of sinus rhythm but stopped 6/52 later due to thyroid dysfunction and intolerance. Had recurrent A fib and DHF off Amiodarone.
A young lady with AF : AF ablation
Initiation and maintenance of AF
A young lady with AF : Follow-up post ablation 12 months post procedure: patient was on sinus rhythm, completely asymptomatic, off ATT
Atrial Fibrillation: what a general cardiologist needs to know?
Atrial Fibrillation: Rate or Rhythm?
Atrial Fibrillation: what a general cardiologist needs to know?
Atrial Fibrillation: Rate or Rhythm?
Atrial Fibrillation: Rate or Rhythm?
Atrial Fibrillation: Rate or Rhythm?
Summary AF is common in HF and often disabling arrhythmia The goals of AF therapy are to prevent thromboemolic events and to improve patient quality of life Decision to anticoagulate should be based on patient risk factors, almost all HF with AF needs anticoagulation.
Summary Few drugs are available for rhythm control strategy in HF patients. AF ablation should be considered especially in patients with HF related to AF.
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