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Atrial Fibrillation

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91 views4 pages

Atrial Fibrillation

Uploaded by

api-753059042
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Ethan Robinson, Pharm.D.

Topic Discussion | August 23, 2023

What is Atrial Fibrillation?

• Supraventricular tachyarryhthmia characterized by rapid, uncoordinated atrial impulses


and contractions resulting in ineffective pumping of blood from the atria into the
ventricles.
• In simpler terms “quivering of the atria”

Signs/symptoms

• Can be asymptomatic
• Common: fatigue, palpitations, syncope, shortness of breath, and hypotension

Risk Factors

• Advanced Age - Over one-third of AFib patients are > 80 yo


• Ectopic foci (left atrial myocardial sleeves in pulmonary veins)
• Inflammation (c-reactive protein and IL-6)
• Open Heart Surgery
• Hypertension & Heart Failure
• Obesity & Diabetes
• Hyperthyroidism
• Obstructive Sleep Apnea
• Smoking & Binge Drinking
• Family History/European Ancestry
Diagnosis

• ECG with irregular R-R intervals and absence of distinct, repeating P waves
• Rapid Pulse

Classification

• Valvular AFib denotes patients with moderate to severe mitral stenosis or a


mechanical heart valve.
• Non-valvular AFib does NOT mean there is no valvular dysfunction.
o Paroxsymal: < 7 days due to intervention or spontaneous return of sinus rhythm
o Persistent: > 7 days
o Long-standing Presistent: > 12 mo
o Permanent: When both patient and clinician agree that no further interventions
will be made to restore sinus rhythm

Complications

• AFib increases risk of risk of heart failure by 3x due to LV dysfunction and stroke by 5x
due to clots that develop primarily in the left atrial appendage!

Pharmacological Treatment

Rate Control

• Beta-blockers (there are several!)


o IV options: metoprolol tartrate, esmolol and propranolol
• Non-DHP Calcium Channel Blockers: verapamil and diltiazem
o CI in Heart Failure with reduced ejection fraction
• Digoxin (serum concentration of 0.8-2.0 ng/mL)
o 2nd Line
o DDIs with verapamil & amiodarone
o Increased risk of mortality

Heart Rate Goals

• Strict < 80 bpm at rest


• Lenient < 110 bpm at rest
• Without symptomatic bradycardia
Rhythm Control

Class Ia (Na+ channel blockers): quinidine, procainamide, disopyramide

• Na+ channel blocker that slows deporalization and lengthens action potential

Class Ic: flecainide, propafenone

• Na+ channel blocker that slows depolarization


• not as effective for cardioversion
• “pill in pocket”

Class III: amiodarone, dronedarone, dofetilide, ibutilide (IV), sotalol

• primarily K+ channel blockers that slow repolarization; sotalol has beta blockade;
amiodarone also blocks calcium channels and has beta blockade
• amiodarone is the most effective but comes with the most side effects
• dofetilide/ibutilide and sotalol must be initiated in the hospital due to risk of torsades
de pointes

Dofetilide (Tikosyn) Protocol: monitor QTc interval at baseline and after each dose, record
weight daily to calculate CrCl, replace potassium and magnesium

Anti-coagulation (stroke prophylaxis)

• CHA2DS2-VASc Score
o Score ≥2 for men and ≥3 for women, anti-coagulation is indicated

First line: DOACs: apixaban (Eliquis), rivaroxaban (Xarelto), edoxaban (Savaysa) - Factor Xa
Inhibitors (ENGAGE AF-TIMI 48)

Dabigatran (Pradaxa) - Direct thrombin Inhibitor

Second line: Warfarin (INR Goals of 2-3 for most patients and 2.5-3.5 for mechanical mitral
valves)

• Bridging NOT recommended unless high risk for thrombosis superseding bleeding risk
(BRIDGE)

Rivaroxaban preferred if BMI ≥40

Warfarin and low-dose apixaban are options for dialysis patients

Research still needed to compare efficacy/safety of different NOACs and monitoring


parameters
Non-surgical Procedures

• Electrical Cardioversion
o Recommended to provide 3 weeks of anticoagulation or TEE to visualize clots
before procedure
• Catheter ablation
o Common sites are pulmonary veins and the AV node

Surgical Procedures

• Pacemaker Implant
• Watchman Device/LAA Occlusion

References

2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation

2019 AHA/ACC/HRS Focused Update

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