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Atrial fibrillation AF is the most commonly encountered arrhythmia in clinical practice. Aging populations coupled with improved outcomes for many chronic medical conditions has led to increases in AF diagnoses. AF is also known to be associated with an increased risk of adverse events such as transient ischemic attack, ischemic stroke, systemic embolism, and death. This association is enhanced in select populations with preexisting comorbid conditions such as chronic heart failure.
The aim of this review is to highlight the advances in the field askeo cardiology in the management of AF in both acute and long-term settings.
We will also review the evolution of anticoagulation management over the past few years and landmark trials in the development of novel oral anticoagulants NOACsreversal agents for new NOACs, nonpharmacological options to anticoagulation therapy, and the role of implantable loop recorder in AF management. The prevalence of atrial fibrillation AF ranges from 0. There is an increased prevalence of AF in age-adjusted male population as compared to women.
Caucasians have a higher prevalence of AF at 2. This shows the strong correlation between worsening cardiac function, age, and AF. AF requires a trigger to begin. The trigger is usually in the form of either automatic foci of tachycardia or multiple wavelets extending through the left atrium. The substrate used for maintenance of arrhythmia is commonly heterogeneous tissue.
Enhanced focal automaticity occurs most commonly in the pulmonary veins PVswhich generate microreentrant circuits that extend into adjacent left atrial tissue. The risk of thromboembolism persists even after cardioversion secondary to a phenomenon known as atrial stunning. Atrial dysfunction is most pronounced immediately following restoration of sinus rhythm and abates typically within days but has been described as far out as 3—4 weeks.
Initial encounters with patients with AF should focus on the hemodynamic stability. Hemodynamic instability results from compromised ventricular diastolic filling and myocardial oxygen delivery, particularly in patients with AF with rapid ventricular response. In the absence of hemodynamic compromise the management of AF is guided by symptomatology and its duration [ Figure 1 ].
This specifically involves identifying exercise capacity and functional capacity, which is inferred from generalized complaints of fatigue and the absence or presence of syncope. Establishing the presence or absence of symptoms and their duration in AF patients is paramount in making decisions regarding long-term rate versus rhythm control strategy.
Lastly, it is important to identify and effectively manage other risk factors such as obesity, thyroid disorder, and sleep apnea. Acute Management of new onset atrial fibrillation LAA: Left atrial appendage; Full anticoagulation: Patients presenting with evidence of hemodynamic or myocardial compromise should receive immediate interventions to restore sinus rhythm or rapidly reduce ventricular rates.
In the absence of hemodynamic instability, synchronized direct-current cardioversion DCCV should be an elective procedure. Particular attention should be given to the ability of patients to tolerate anticoagulation for at least 4 weeks post DCCV.
For acute rate control, beta blockade BBcalcium channel blockade CCBdigoxin, or amiodarone may be considered. Selection of one agent over another is guided primarily by comorbid conditions including the presence or absence of CHF and the potential for an existing accessory pathway of atrioventricular AV conduction preexcitation. Beta-adrenergic antagonists are most effective in states of high catecholamine release, including the perioperative period and critical illness.
Intravenous esmolol BB and diltiazem CCB have similar heart rates achieved at 2 and 12 h, respectively. Both portend a negative inotropic effect in concert with preferential AV node slowing which may accelerate ventricular activation in patients with accessory pathways leading to ventricular rate acceleration and ventricular fibrillation.
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In the setting of a patient with CHF, consideration may be given to digoxin though a vagotonic mechanism of action digoxin may transiently slow AV conduction.
In the setting asiep advanced CHF or preexcitation amiodarone may be considered. Management of atrial askdp breakthrough with rapid ventricular response AAD: Direct current cardioversion; TEE: Ibutilide is an intravenous AAD, which is usually used for pharmacologic cardioversion in normal heart structure and normal QT interval.
Long-term management of AF involves effectively managing symptoms with either rate or gra control strategies in addition to prevention of thromboembolism. These goals are not mutually exclusive. Quality of life QOL evaluations have demonstrated no significant difference between patients ascribed to rate control strategies versus those placed askdp rhythm control strategies, with the exception of one study; which was a status postsurgical Maze procedures.
Similarly, concurrent anticoagulant therapy appears to negatively affect perceived QOL. However, novel anticoagulants are significantly reducing the burden associated with routine anticoagulation monitoring. Oral BB has been shown to be the best single agent for rate control.
Digoxin is used in patients with CHF. AV node and permanent pacemaker are a well-established rate control strategy in medically refractory AF. Significant improvement in QOL, left ventricular ejection fraction LVEF as well as exercise endurance improves in patients who underwent AV node ablation and pacing as a rate control strategy. Antiarrhythmic therapy is tailored upon structural cardiac features and guided by evidence-based both on the type of AF and side effect profile aakep the antiarrhythmic drugs AAD considered.
Classification of the AAD is based on the mechanism of action. Efficacy of anti-arrhythmic drugs on maintaining sinus rhythm SR: Therefore, we recommend checking liver function test frequently in the first few weeks.
The relatively low rates of success for AADs coupled with the specific long-term potential side effects have resulted in ablative therapy as an alternative second-line therapy for the maintenance of sinus rhythm. Current protocols seek to isolate the PVs via radiofrequency ablation or balloon cryoablation. Catheter radiofrequency ablation or balloon cryoablation is superior over AADs in patients with paroxysmal or persistent AF.
Complications of AF ablation therapy have been reported in 4. Death accounts for 0. Atrio-esophageal AE fistula is the deadly aakep and accounted for 0. Other complications include cardiac tamponade 1. Minor complications include femoral pseudoaneurysm and arteriovenous fistula. Absolute contraindications to gez include intolerance to anticoagulation. This is since anticoagulation therapy is required postablation.
The presence of LAA thrombus is also an indication as well as severe mitral valve disease or mechanical mitral valve prosthesis and severe pulmonary hypertension. Regardless of the strategy of symptom control, every patient needs to be evaluated for thromboembolic risk.
An appropriate strategy must also be identified at the time of diagnosis and re-evaluated with each clinical encounter. Maintenance of anticoagulation in the immediate setting is critical to prevent systemic thromboembolism including stroke following pharmacologic or electrical cardioversion, which occurs within the first 3 days of restoration of sinus rhythm.
Epidemiologic studies showed the lowest incidence of thromboembolism at 1. A history of ischemic stroke or TIA is the largest single risk factor for recurrent stroke with a relative risk of 2. Echocardiographic evidence of CHF is an independent risk factor for stroke. The rationale for anticoagulant or antiplatelet therapy should be guided by the interaction of these known risk factors.
Aspirin has been evaluated independently in 6 trials. A meta-analysis of this demonstrates ggea marginal protection against stroke with a stroke rate of 1.
Similarly, gra populations benefit most from oral anticoagulation askkep to aspirin therapy. It has a slow onset that often requires bridging with intravenous heparin or subcutaneous low molecular heparin. Hemodialysis askp rapidly reduce the dabigatran blood concentration and anticoagulant effect for few hours.
Dabigatran is noninferior to warfarin in preventing systemic thromboembolism. Dabigatran has significantly lower incidence of hemorrhagic stroke, but a higher incidence of gastrointestinal bleeding compared to warfarin therapy. The recommended dose is 5 mg twice daily for patients with nonvalvular AF and preserved renal function.
Apixaban is not azkep more effective than warfarin at preventing stroke, but also safer in terms of bleeding risk and risk of death.
Edoxaban is associated with significantly lower rates of bleeding and death from cardiovascular causes compared to warfarin. Andexanet alfa is an antidote for patients anticoagulated with apixaban and rivaroxaban. Whereas, Idarucizumab is an antidote for patients anticoagulated with dabigatran. Both agents should be utilized if patients develop major bleeding or need an emergent surgery.
Anticoagulant therapy carries the potential of bleeding complications; HAS-BLED score calculates the major bleeding risk utilizing clinical history in patients with AF.
Higher scores confer increased bleeding risk in a nonlinear fashion with a score of zero suggesting a bleeding rate of 0. Scores more than 5 were too rare to predict outcomes. These devices are intended to prevent thromboembolism in patients with AF, who are intolerant to OAC.
These devices primarily occlude the LAA with the intent to reduce the incidence of thrombus formation and thereby obviate the need for anticoagulation. Due to the high prevalence of AF, almost every cardiologist and internist have a decent vea patient population with a diagnosis of AF. The initial encounter could occur during fea acute and unstable hemodynamic presentation that requires an asoep DCCV then initiation of anticoagulation if not contraindicated.
Systematic and detailed evaluation of the patient with stable AF should be implemented including assessment of the risk of thromboembolism, presence of CHF, tachycardia-induced cardiomyopathy, presence of preexcitation, and other comorbidities that will influence the management of AF such as sleep apnea, thyroid disorder, pulmonary disease, obesity, and diabetes mellitus.
The long-term management depends on the symptoms and the duration of AF.
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Less than 48 h AF could be cardioverted safely back to sinus rhythm followed with the initiation of anticoagulation therapy. Drug therapy that is used for rate control strategy is guided by patient symptoms such as palpitations, decreased functional capacity, and exercise intolerance as well as tolerance to the medications.
Pacemaker and AV node ablation are an alternative to rate control therapy if the patient is intolerant to the drug therapy. AAD in rhythm control strategy is guided by the cardiac function as well as the pharmacokinetic, drug-drug interaction, and metabolism of AAD.
Ablation therapy is an alternative option for the AAD in rhythm control therapy. National Center for Biotechnology InformationU. Journal List Avicenna J Med v. Author information Copyright and License information Disclaimer. Abstract Atrial fibrillation AF is the most commonly encountered arrhythmia in clinical practice.