Antiarrhythmic drug PPT Cardiology Arrhythmia

Antiarrhythmic drug PPT Cardiology Arrhythmia

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  Antiarrhythmic drugs &Role of Flecainide in Atrial Fibrillation Management Dr. Md. Wajed Hossain FCPS Part 2 Trainee Dept. of Cardiology MuMCH
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   Heart Rateis between 60-100 bpm  Every beat should originate from SA node  Cardiac impulse should propagate through normal conduction pathway  Impulse should pass through normal velocity Normal Cardiac Rhythm
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  AV Node ImpulseConduction AV Bundle Impulse Conduction Pacemaker Impulse Generation Purkinje Fibers Impulse Conduction Normal Conduction Pathway
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  • Cardiac Ischemia •Hypoxia • Acidosis or Alkalosis • Electrolyte Abnormalities • Excessive catecholamine exposure • Autonomic influences • Drug toxicity (E.g. Digitalis) • Overstretching of cardiac fibers • Presence of scarred/diseased tissues Factors that trigger Arrhythmia
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  Abnormal impulse generation: Depressed automaticity  Enhanced automaticity Triggered activity (after depolarization):  Delayed after depolarization  Early after depolarization Abnormal impulse conduction:  Conduction block  Re-entry phenomenon  Accessory tract pathways Mechanism of Cardiac Arrhythmia
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  Atrial fibrillation (AFib)is an irregular and often very rapid heart rhythm. AFib can lead to blood clots in the heart. Atrial Fibrillation
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  Prevalence and Incidenceof AF is increasing and projected to double between 2010 and 2030 estimated individuals with AF worldwide in 2020 At least 5.6 million individuals with AF in USA in 2015 - about 11% estimated cases were undiagnosed Overall lifetime risk: • 30-40% in White individuals • 20% in African American individuals • 15% in Chinese individuals In Medicare beneficiaries, the most frequent outcome in 5-yrs after AF diagnosis was death (19.5% at 1-yr; 48.8% at 5- yrs) AF is associated with increased risks: • 1.5-to 2-fold risk of death • 2.4-fold risk of stroke • 1.5-fold risk of CI/ dementia • 1.5-fold risk of MI • 2-fold risk of SCD • 5-fold risk of HF • 1.6-fold risk of CKD • 1.3-fold risk of PAD Abbreviations: AF indicates atrial fibrillation; CI, cognitive impairment; CKD, chronic kidney disease; HF, heart failure; MI, myocardial infarctions; PAD, peripheral arterial disease; SCD, sudden cardiac death; yr, year; and yrs, years. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. 50 million
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  Causes of AF
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  Mechanisms and PathwaysLeading to AF AHA/ACC 2023
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  Diagnosis of AF
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  Antiarrhythmic Drugs
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  VAUGHAN-WILLIAMS Classification Class MechanismExample Action Remark Ia Na+ channel blocker Quinidine, Procainamide Change the slope of phase 0 Can abolish tachyarrhythmia caused by reentry circuit Ib Lidocaine Flecainide, Propafenone Ic II β blocker Metoprolol, Propranolol ↓ heart rate and conduction velocity Can indirectly alter K and Ca conductance III K+ channel blocker Sotalol, Amiodarone action potential duration or effective refractory period; Delay repolarization Inhibit reentry tachycardia IV Ca++ channel blocker Verapamil, Diltiazem Slowing the rate of rise in phase 4 of SA node ↓ conduction velocity in SA and AV node Miscellaneou s Adenosine, Digoxin
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  Guideline Recommendation of Atrial Fibrillation
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  Patient with first-diagnosed AF
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  Patient with paroxysmal AF
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  Patient with persistent AF
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  Patient with permanent AF
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  ESC 2024
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  Primary Prevention ofAtrial Fibrillation Lifestyle and Risk Factor Management Obesity Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 30 Physical Activity Alcohol Consumption Smoking Diabetes mellitus Hypertension
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  Treatment: Rate Controlin AF Differen t Abbreviations: AF indicates atrial fibrillation; bpm, beats perminute; and vs, versus. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 31 factors that guide decision of Rate vs Rhythm therap y Shared decision making & patient preferenc e Presence of Heart Failure Medicatio n Profile Clinical presentatio n Comorbiditi es Objectives of Rate Control: • • • • • • Resting heart rate < 100-110 bpm Reduce symptoms Reduce risk of tachycardia-induced cardiomyopathy or improve heart function of patients with tachycardia-induced cardiomyopathy Reduce inappropriate shock in patients with implantable defibrillators Enhance biventricular pacing in patients with cardiac resynchronization therapy use Reduce risk of hospitalization
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  Pharmacological Agents forRate Control in AF Rate Control Agents nanogram; NDCC, nondihydropyridine calcium channel blocker; PRN, as needed; pts, patients; and SA, sinoatrial. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 32 Beta-Blockers • Slows AV nodal conduction • Block B-1 receptors Digoxin • Positive inotropic and vagotonic effects • Could be useful in HFrEF pts IV Magnesium • Blocks slow inward calcium channels of SA and AV node Amiodarone • Useful in critical ill pts who cannot tolerate AV nodal slowing agents • Can result in pharmacologic cardioversion NDCC • Slow AV nodal conduction • Negative inotropic and chronotropic effect Non- DHP CCB IV Oral Maintenan ce dose Diltiazem 0.25 mg/kg IV over 2 mins. May repeat 0.35 mg/kg over 2 mins; then 5-15 mg/hr continuous infusion 120 – 360 mg daily (ER) Verapamil 5 to 10 mg over 2 ≥ minutes (may repeat twice); then 5 mg/hr continuous infusion (max 20 mg/hr) 180 – 480 mg daily (ER) Agent IV Oral Maintenan ce dose Amiodarone 150-300 mg I V over 1 hr , then 10- 50 mg/h over 24 hrs 100 – 200 mg daily Digoxin* *Increased mortality at plasma concentrations exceeding 1. 2 ng/mL 0.25 – 0.5 mg over mins; repeat doses of 0.25 mg every 6 hrs (max 1.5 mg/24 hrs) 0.0625 – 0.25 mg daily Beta- Blocker IV Oral Maintenan ce dose Metoprolol tartrate 2.5-5 mg bolus over 2 mins; up to 3 doses 25 – 200 mg twice daily Metoprolol succinate N/A 50 - 400 mg daily Atenolol N/A 25 – 100 mg daily Bisoprolol N/A 2.5 – 10 mg daily Carvedilol N/A 3.125- 25 mg twice daily Esmolol 500 mcg/kg bolus over 1 min; then 50 – 300 mcg/kg/min N/A Nadolol N/A 10-240 mg daily Propranolol 1 mg over 1 min; repeat PRN every 2 mins; up to 3 doses 10-40 mg three to four times daily Abbreviations: AF indicates atrial fibrillation; AV, atrioventricular; ER, extended release; HFrEF, heart failure with reduced ejection fraction; hr , hour; hrs, hours; IV, intravenous;kg, kilogram; min; minute; mins,minutes; mg, milligram; mcg, microgram; ng,
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  Approach to AcuteRate Control in AF with Rapid Ventricular Response Hemodynamically Stable? Direct-Current Cardioversion(1) Decompensated HF? BB, verapamil, or diltiazem (1) Digoxin (2a) Amiodarone (2b) Addition of Magnesium to AV nodal blockage (2a) IV Amiodarone* (2b) Verapamil, diltiazem (3: Harm) No Yes No Yes *Contraindicated in patients with moderate-severe LV dysfunction regardless of decompensated HF. Abbreviations: AF indicates atrial fibrillation; AV, atrioventricular; BB, beta-blocker; HF, heart failure; IV, intravenous; and LV, left ventricular. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 33
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  Approach to LongTerm Rate Control of AF Abbreviations: AF indicates atrial fibrillation; BB, beta-blocker; LVEF, left ventricular ejection fraction; and NDCC, nondihydropyridine calcium channel blocker. Long-term rate control BB (1) LVEF ≤4 0 % Digoxin (2a) NDCC (Diltiazem, Verapamil) (3: Harm) BB or NDCC (1) LVEF > 4 0 % Digoxin (2a) Permanent AF Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 29 Dronedarone (3: Harm)
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  Recommendations for AtrioventricularNodal Ablation COR RECOMMENDATIONS 1 In patients with AF and a persistently rapid ventricular repose who undergo AVNA, initial pacemaker lower rate programming should be 80 to 90 bpm to reduce the risk of sudden death. 2b In patients with AF and uncontrolled rapid ventricular response refractory to rate-control medications, AVNA can be useful to improve symptoms and QOL. 1 In patients with AF scheduled to have an AVNA, implantation of a pacemaker prior to procedure is recommended to ensure adequacy of the pacing leads before performing the ablation. 2b In patients with AF and normal EF undergoing AVNA, conduction system pacing of the His bundle or left bundle area may be reasonable. Abbreviations: AF indicates atrial fibrillation; AVNA, atrioventricular nodal ablation; bpm, beats per minute; EF, ejection fraction; and QOL, quality of life. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 35
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  Goals of RhythmControl Therapy in AF Rhythm control in patients with Recent AF Diagnosis ( < 1 year) Reduced LV function &Persistent AF AF and HF Symptomatic AF Rhythm control can be useful to reduce hospitalizations, stroke, and mortality (2a) In patients with AF, rhythm-control strategies can be useful to reduce the likelihood of AF progression.(2a) A trial of rhythm control recommended to evaluate if AF is contributing to reduced LV function (1) Rhythm control can be useful for improving symptoms and outcomessuch as mortality and hospitalizations for HF and ischemia (2a) Rhythm control can be useful to improve symptoms (2a) In patients with AF where symptoms associated with AF are uncertain, a trial of rhythm control (eg, cardioversion or pharmacological therapy) may be useful to determine what if any symptoms are attributable to AF (2b) Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 36 In patients with AF, rhythm-control strategies may be useful to reduce the likelihood of development of dementia or worsening cardiac structural abnormalities.(2b) Abbreviations: AF indicates atrial fibrillation; HF, heart failure; and LV, left ventricular.
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  Electrical and PharmacologicalCardioversion of AF Hemodynamicall y Stable? Electrical cardioversion can be performed as initial rhythm-control strategy or after unsuccessful pharmacological cardioversion. (1) No fraction; pts, patients; PTTP , pill-in-the-pocket; QRS, QRS interval; and VF, ventricular fibrillation. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 37 Yes Or in situations when electrical cardioversion is preferred but cannot be performed. (2a) Immediate electrical cardioversionshould be performed (1) Recommendations for pharmacologic cardioversion COR RECOMMENDATIONS 2a Ibutilide is reasonable for pharmacological cardioversion for pts w/o depressed LV function (LVEF <40%). (1) 2a IV amiodarone is reasonable for pharmacological cardioversion, although time to conversion is generally longer than other agents (8-12 hours). (2a) 2a Recurrent AF occurring outside the hospital, the PITP approach with a single oral dose of flecainide or propafenone, with concomitant AV nodal blocking agent,15 is reasonable for pharmacological cardioversion if previously tested in a monitored setting. (2a) 2b Use of IV procainamide may be considered for pharmacological cardioversion when other intravenous agents are contraindicated or not preferred. (2b) Recommendations for electrical cardioversion COR RECOMMENDATIONS 1 Electrical cardioversion, energy delivery should be confirmed to be synchronized to the QRS to reduce the risk of inducing VF. (1) 2a In elective electrical cardioversion, the use of biphasic energy of at least 200 J as initial energy can be beneficial to improve success of initial electrical shock. (2a) 2a In pts undergoing elective cardioversion, with longer duration of AF or unsuccessful initial shock, optimization of electrode vector , use of higher energy, and pretreatment with antiarrhythmic drugs can facilitate success of electrical cardioversion. (2a) 2b In pts with obesity and AF, use of manual pressure augmentation and/or further escalation of electrical energy may be beneficial to improve success of electrical cardioversion. (2b) Abbreviations: AF indicates atrial fibrillation; AV, atrioventricular; IV, intravenous; LV, left ventricular; LVEF, left ventricular ejection
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  Antiarrhythmic Drugsfor Maintenanceof Sinus Rhythm Amiodarone (2a) Atrial fibrillation Normal LV function, no prior MI or significant structural heart disease Dofetilide Dronedarone Flecainide Propafenone (2a) Sotalol (2b) Prior MI or significant structural heart disease, including HFrEF (LVEF 4 0 % ) ≤ Flecainide Propafenone (3: Harm) Amiodarone Dofetilide (2a) Sotalol (2b) NYHA FC I I I or IV or recent decompensated Hf Dronedarone (2a) Dronedarone (3: Harm) No ventricular ejection fraction; MI, myocardial infarction; and NYHA FC, New York Heart Association Functional Class. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 33 Yes Considerations: • Risk of development of MI and structural heart disease • The need for in-hospital initiation of antiarrhythmic drugs • Baseline and follow-up tests Abbreviations: HF indicates heart failure; HFrEF, heart failure reduced ejection fraction; LV, left ventricle; LVEF, left
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  Anticoagulation Management StrategyBefore & After AF Ablation years, sex category; DOAC, direct oral anticoagulant; INR, international normalized ratio; and OAC, oral anticoagulant. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 36 Prior to ablation COR RECOMMENDATIONS 1 Catheter ablation should be performed on uninterrupted therapeutic anticoagulation with a goal INR of 2.0 to 3.0. 1 If patient on a DOAC, catheter ablation should be performed with either continuous or minimally interrupted oral anticoagulation. After ablation COR RECOMMENDATIONS 1 OAC should be continued for at least 2 to 3 months after the procedure with a longer duration determined by underlying risk. 1 Continuation of longer-term OAC should be dictated according to the patients’ stroke risk (eg, CHA2DS2-VASc score 2). ≥ Abbreviations: AF indicates atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 ≥ years (doubled), diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism (doubled), vascular disease, age 65 to 74
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  AF Management inPatients with HF GDMT, Thromboembolism prophylaxis, Risk factor modification Electrical Cardioversion (1) Pharmacological Cardioversion (2a) NDCC (Diltiazem, Verapamil) (3:Harm) Cardioversion if indicated Rate Control Evaluate if appropriate for rhythm control with catheter ablation – see next slide L VEF< 4 0 % L VEF> 4 0 % Beta-Blockers (1) Digoxin (2a) IV Amiodarone Acute rate control (2a) Beta-Blockers or NDCC (1) Digoxin (2a) IV Amiodarone Acute rate control (2a) Abbreviations: AF indicates atrial fibrillation; HF, heart failure; IV, intravenous; and NDCC, non-dihydropyridine calcium channel blockers. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 37
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  AF Management inPatients with HF Abbreviations: AF indicates atrial fibrillation; AV, atrioventricular; CMP, cardiomyopathy; CMR, cardiac magnetic resonance; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; and wk, week. Evaluate if appropriate for rhythm control with catheter ablation – see previous slide Likely to benefit from catheter ablation • AF-mediated CMP suspected • Early stage of HF • No significant ventricular scar on CMR • No or mild atrial fibrosis • Paroxysmal and early persistent AF • Younger pts w/o significant other comorbidities Less Likely to benefit from catheter ablation • Advanced HF • Significant ventricular scar on CMR • Severe atrial myopathy (dilation/fibrosis) • Long-standing persistent AF • Prior failed ablations • Advanced age or multiple comorbidities HFrEF HFpEF AF catheter ablation (1) Long-term surveillance for recurrent AF (in AF-induced CMP and recovered LVEF (2a) Dronedarone NYHA Class I II / I V HF or decompensated HF in past 4 wk (3:Harm) AF catheter ablation (2a) Decision for pharmacological rhythm vs rate-control strategy Pharmacological cardioversion and maintenance of SR after cardioversion Repeat ablation HFrEF (LVEF<50%) Uncontrolled rate + rhythm control failed or not appropriate: AV nodal ablation + pacing (2a) Uncontrolled rate with biventricular pacemaker in place without effective pacing % : AV Nodal ablation (2a) Left bundle of His bundle pacing as alternative to biventricular pacing (2b) No clinical AF Recurrent AF Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 42
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  Management of EarlyOnset AF, Athletes, Obesity, Hyperthyroidism, Pulmonary disease Abbreviations: AF indicates atrial fibrillation; COPD, chronic obstructive pulmonary disease; DOACs, direct-acting oral anticoagulants; EP , electrophysiologic; HF, heart failure; HTN, hypertension; kg/m2, kilogram per meters squared; MI, myocardial ischemia; PH, pulmonary hypertension; PV, pulmonary vein; SR, sinus rhythm; and SVT, supraventricular tachyarrhythmias. Age Athlete s Obesity (Class I I I ) Hyperthyroidism Pulmonary Disease < 3 0 yr < 4 5 yr BMI 4 0 ≥ kg/m2 Bariatric surgery COPD PH with Pulmonary Vascular Disease Rhythm control- catheter ablation with PV isolation is reasonable (2a) EP study to evaluate and treat reentrant SVT (2b) Targeted ablation may be reasonable (2b) The following may be reasonable: • Referral for genetic counselin g • Genetic testingfor rare pathogenic variants • Surveillance for cardiomyopathy or arrhythmia syndromes (2b) DOACs reasonable over warfarin (2a) Warfarin may be reasonable over DOACs due to DOAC drug absorption concerns (Class 2b) Anticoagulation until euthyroid and SR maintained (1) Rate control- Cardio-selective beta-blockers especially in MI and HF (2a) Rhythm control- strategy is reasonable (2a) Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 43
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  Management of AFin Cardio-Oncology, Liver disease, and CKD Cardio-Oncology Multidisciplinary communication & SDM (Reduce drug interactions; QTc prolongation; proarrhythmia; bleeding; and thromboembolism) (1) Cancer and AF DOACs preferred overVKAs for stroke risk reduction (2a) Mild or Moderate Liver Disease (Child-Pugh Class A or B) CKD/Kidney Failure at Elevate Stroke Risk Cancer withrisk for AF CKD Stage 3 CKD Stage 4 ESRD/ Dialysis Increased vigilance for incident AF and treatment of contributing factors (2a) Class A: Any DOAC (2a) Class B: Apixaban, Dabigatran, or Edoxaban preferred over warfarin (2a) Evidence based doses of direct thrombin or factor Xa inhibitors OR Warfarin (1) Warfarin OR labelled doses of DOACs (2a) It might be reasonable to prescribe warfarin (INR 2-3) OR Apixaban evidence-based dose (2b) OACs in the absence of clinically significant liver disease-induced coagulopathy or thrombocytopenia (2a) Patients with AF and moderate liver disease (Class B): Rivaroxaban is contraindicated due to increased risk of bleeding (3:Harm) Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 44 Abbreviations: AF indicates atrial fibrillation; CKD, chronic kidney disease; DOACs, direct-acting oral anticoagulants; ESRD, end stage renal disease; INR, international normalised ratio OACs, oral anticoagulants; QTc, QT interval corrected for heart rate; SDM, shared decision-making; and VKAs, vitamin K antagonists.
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  Pregnancy and theAF Patient Pregnancy with AF Direct-current cardioversion (1) Elevated stroke risk Persistent AF No Structural heart disease Pharmacologic cardioversion: IV Procainamide may be considered (2b) Rhythm control: Flecainide , Sotalol are reasonabl e (2a) Rate control: Beta blocker (propranolol/metoprol ol) & digoxin either alone or in combination with beta blocker are reasonable as first- line agents (2a) SDM regarding anticoagulation with the recognition that no anticoagulation strategy is completely safe for both the mother and fetus (2b) Stab le AF Abbreviations: AF indicates atrial fibrillation; IV, intravenous; and SDM, shared decision- making. Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 45
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  Prevention and Treatmentof AF After Cardiac Surgery Prevention of AF After Cardiac Surgery Patients at high risk for postop AF: Short-term prophylactic beta- blockers or amiodarone (2a) CABG, aortic valve, ascending aortic aneurysm operations: posterior left pericardiotomy (2a) Hemodynamically stable Rate control: Beta-blocker OR CCB (1) Hemodynamically unstable or poorly tolerated AF Treatment of AF After Cardiac Surgery Consider anticoagulation when deemed safe from surgical bleeding (2a) Rhyth m control (1) 30 to 60-day postop rhythm assessment ± cardioversion if AF does not revert to SR (2a) Abbreviations: AF indicates atrial fibrillation; bpm, beats perminute; CABG, coronary artery bypass graft surgery; CCB, calcium channel blocker; HR, heart rate; pts, patients; and SR, sinus rhythm. Direct current cardioversion with antiarrhythmic drug therapy (1) Rate control (target HR < 1 0 0 bpm) with beta- blocker or CCB (1) Joglar , J. A. et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 46
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  Flecainide
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  Class IC antiarrhythmic drug Flecainide isa …
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  Introduction Flecainide’s was firstsynthesized in 1972. Flecainide was approved for medical use in the United States on 31 October 1985 for the treatment of supraventricular and ventricular tachyarrhythmias.
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  Mechanism of action Flecainideis a sodium channel blocker. The antiarrhythmic actions are mediated through effects on sodium channels in Purkinje fibers. It stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses.
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  Absorption Peak plasmaconcentration attained at about 3 hours Bioavailability Oral bioavailability is approximately 85–90% Half life Plasma half-life is about 20 hours (range 12-27 hours) Excretion 30% of oral dose is excreted in urine as unchanged drug Pharmacokinetics
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  Therapeutic uses • AtrialFibrillation • Atrial Flutter • Paroxysmal Supraventricular Tachycardia • Supraventricular Tachycardia • Ventricular Tachycardia • Wolff-Parkinson-White Syndrome
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  Guideline Recommendation
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  Recommendations Class Level flecainideis recommended when pharmacological cardioversion of recent- onset AF is desired, excluding patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease. I A Pharmacological cardioversion of AF Class I - Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. Level A - Data derived from multiple randomized clinical trials or meta-analyses.
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  Recommendations Class Level Flecainideis recommended in patients with AF requiring long-term rhythm control to prevent recurrence and progression of AF excluding those with impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease I A Long-term maintenance of sinus rhythm Class I - Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. Level A - Data derived from multiple randomized clinical trials or meta-analyses.
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  Recommendations Class Level Asingle oral dose of flecainide (pill-in-the- pocket) should be considered for patient- led cardioversion in selected patients with infrequent paroxysmal AF, excluding those with severe left ventricular hypertrophy, HFrEF, or coronary artery disease. IIa B Pharmacological cardioversion of AF Class IIa - Weight of evidence/opinion is in favour of usefulness/efficacy. Level B - Data derived from a single randomized clinical trial or large non-randomized studies.
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  Recommendations Class Level Forpatients with recurrent AF, the “pill-in- the-pocket” (PITP) approach with a single oral dose of flecainide with a concomitant atrioventricular nodal blocking agent is reasonable for pharmacological cardioversion IIa A Recommendations for pharmacological cardioversion of AF Level A - Data derived from multiple randomized clinical trials or meta-analyses. Class IIa - Weight of evidence/opinion is in favour of usefulness/efficacy.
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  Recommendations Class Level Forpatients with AF and no previous MI, or structural heart disease, or ventricular scar or fibrosis, use of flecainide is reasonable for long-term maintenance of sinus rhythm. IIa A Long-term maintenance of sinus rhythm Level A - Data derived from multiple randomized clinical trials or meta-analyses. Class IIa - Weight of evidence/opinion is in favour of usefulness/efficacy.
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  Clinicals Trials
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  22 trials (2,320patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischemic heart disease vs. placebo or rate-control. Conclusion: Single oral dose Class1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide is superior to propafenone. Amiodarone is as lower acting alternative.
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  Dosage guideline
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   For acutecardioversion of paroxysmal AF  Mean conversion time 2 hours  An initial inpatient cardioversion should have been successful  Must be taking an AV nodal blocking agent  AV nodal blocking agent should be given at least 30 min before flecainide  Dose: <70 kg: 200mg ≥70kg: 300mg Pill-in-the-pocket
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  Use in specialpopulation
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  Contraindications Patients with Ischemicheart disease, structural heart disease, preexisting second- or third degree AV block, or with right bundle branch block when associated with a left hemiblock (bifascicular block), presence of cardiogenic shock or known hypersensitivity to the drug.
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  Adverse effects • Dizziness •vision problems (such as blurred vision, problems focusing, seeing spots) • shortness of breath • Headache • Nausea • Shaking • tiredness or weakness • Flecainide has been shown to have teratogenic effects
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  Drug Interactions SSRI  QTprolonging drug
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  • Atrial fibrillation(AF) is one of the most commonly encountered heart conditions. • Flecainide is recommended for pharmacological cardioversion of recent-onset AF. • Flecainide may be considered for long-term maintenance of sinus rhythm, to prevent recurrence and progression of AF. • Flecainide is not for IHD or SHD patient • Flecainide should almost always be prescribed with AV nodal blocker Take Home Message