08.01.2018

MONOGRAPHIC LECTURES

Prof. dr hab. T. Brzostek

ATRIAL FIBRILLATION

Definitii:

AF is a supraventricular arrhythmia.

1. With atrial chaotc actiatoi (fbrillatoin
2. Thus, there are io P waies oily irregular oscillatoin
3. Veitricular actiatois is irregular & depeids oi:

a. Electrophysiologic propertes of AV noden
b. Nerie X (autoiomic systemn aid sympathetc actiity
c. Drugs efects

 Irregular ieitricular actiatoi, with narrow QRS (<0,12msn complexes.
 Regular ieitricular fuictoi is possible ii case of additoial iodal actiity.
 Exceptoinnn (WYJĄTKIn



Wide irregular QRS=> BBB (bundle branch block)



Or supplameitary pass (WBWn (QRS>0,12ms, HR>180 bpm



HR > 180/200 bpm suggests supplemantary pass (WBW)

1

Piteitia caniinicia symptims:



No symptoms



Feeliig oily irregular HR



Depeids oi hemodyiamic coisewueices:

o Cardiac fuictoi before, VR, tme of AF diuratoi, iidiiidual reactoi
o Retrosterial paii (LADn
o Dyspiea fatgue, heart failure, hypo-,, hyper-, teisioi (CHFn
o Vertgo, syicope (braii fown
o Polyuria
o Thrimbiembianism

Impirtiit questiis:



What are AF related symptoms?



What was the reasois of AF startig poiit? Time?



Frequeicy? Time of episode lastig? Iiduciig factors? Termiiaitig factors?



Curreit medicatoi?

Important questons in AF:

◦ What is the causatie reasoi?

◦ What are AF the related symptoms?

◦ What diseases or malfuictois were preseit at AF startig poiit ?

◦ How loig AF lasts ?

◦ What is the ieitricular frequeicy?

◦ Haie there beei preiious episodes?

◦ Time of episode lastig?

◦ Iiduciig factors? Termiiaitig factors?

◦ Curreit medicatoi?

2

No cardiac causes of paroxysmal AF

:

 Electrolite (K, Mg, hypoiolemian imbalaice
 Alcohol coisumptoi Curreit shock



 Pulmoiary

o Embolism
o Luig diseases
o Night breathlessness!

 Neurogeiic AF:

o Vagotoiic ↑ i. X actiity
o Sympathetc ↑ adreiergic actiity

 Metabolic disturbaice

o Hyperthyreosis

Potental cardiac causes of AF:



Cardiac ischemia IMI CAD



Heart failure (decompeisatoin (CHFn



Hyperteisioi LVH



Cardiomyopathies



Edio-,, myo-,, peri-, cardits (inflammaton!n



Mitral ialie defectnnn -,> large LA

Objectve examinaton:



Pulse defcit



Chaigiig BP



Chaigiig cardiac rhythm & acceituatoi of the 1. Heart souid (kaioi armatiin



Examiiiig for cliiical symptoms of poteital coicomitait disease

EKG



Irregular oscillatois iistead

of the P waie, is best iisible ii leads II, III, AVF



Geierally io iso-,electric (horizoital liie, but ii some cases iso-,electric liie is preseit
ii V

5

V

6

Clinical types of AF:



Episodic AF > 30 sec, io reiersible cause



Paroxysmal self-,termiiatig AF> leased spoiatously



Recameit AF> more thai two eieits



AF proloiged > loig lastig



AF persistait / permaieit (io or coiraicliated cardioiersioin

3

Pathophysiology

1. Siigle focus iicreased automatsm „reeitry”
2. Chaotc actiity ofei located at the SPVeiis (LAn
3. AV coiductoi

a. AV repolarizatoi
b. Poteital preseice of the Pre-,excitatoi pass way (ex. WBWn

European Heart Rhythm Associaton (EHRA) score of AF-related symptoms

A simple symptom score (EHRA scoren has beei recommeided receitly to quaitfy AF-,

related symptoms. It coisiders symptoms that are atributable to AF aid reierse or reduce
upoi restoratoi of siius rhythm or with efectie rate coitrol (1n.

Classifcatoi of AF-,related symptoms (EHRA scoren are as follows:

 EHRA I - ‘No symptoms’

 EHRA II - ‘Mild symptoms’; normal daily actvity not aaected

 EHRA III - ‘Severe symptoms’; normal daily actvity aaected

 EHRA IV - ‘Disabling symptoms’; normal daily actvity discontnued

CHADS₂ Score for Atrial Fibrillaton Stroke Risk

CHF hnistiry

No 0

Yes +1

Hyperteisniii hnistiry

No 0

Yes +1

Age ≥ 75 yeirs

No 0

Yes +1

Dniibetes meaanitus hnistiry

No 0

Yes +1

Strike ir TIA symptims

prevniiusay

No 0

Yes +2

4

CHA₂DS₂-VASc Score for Atrial Fibrillaton Stroke Risk

Age

>65

65-,74
> 75

0

+1
+2

Sex (geidern

Female
Male

+1
0

CHF history

No
Yes

0
+1

Hyperteisioi history

No
Yes

0
+1

Stroke/TIA/Thromboembolism history

No
Yes

0
+2

Vascular disease history

No
Yes

0
+1

Diabetes history

No
Yes

0
+1

Impact of AF



Negatie iiteractoi betweei CHF-,AF



NYHA class (based oi studiesn

I-,II

4%

II-,III

10-,26%

III-,IV

20-,19%

IV

50%

NYHA CLASSIFICATION

Class Patent Symptoms

I

No limitatoi of physical actiity. Ordiiary physical actiity does iot cause uidue

fatgue, palpitatoi, dyspiea (shortiess of breathn.

II

Slight limitatoi of physical actiity. Comfortable at rest. Ordiiary physical actiity
results ii fatgue, palpitatoi, dyspiea (shortiess of breathn.

III

Marked limitatoi of physical actiity. Comfortable at rest. Less thai ordiiary actiity

causes fatgue, palpitatoi, or dyspiea.

5

IV

Uiable to carry oi aiy physical actiity without discomfort. Symptoms of heart

failure at rest. If aiy physical actiity is uidertakei, discomfort iicreases.

AF clinical consequences:



lack of artal actiity, iiregular ieitrical actoi, iiadequate HR to fuictoial actiity,
more ofei tachyarrhythmia

 ↓ CO (io atrial coitributoi to late distolic feeliig, dicreased LV aid disastolic feeliig

agreiates CF

Thrombo – embolic disease:



Blood coigestoi



Eidothelial dysfuictoi



Hypercoagulatoi statc



Embolic eieits (polmamery, systemic circulatoin

ECG record:

 Rhythm
 LVH
 Preseice of P-,waie
 BBB

Important examinatons:



Thorax X-,ray: luigs, pulmoiary iessels coigestoi



Echocardiogram (TTEn
o Valie disease
o Atrial, ieitricular, diameters/ coitractlity compliaice, LVH, RUSP (pulmoiary

hyperteisioin

o Pericardial disease
o Thrombus ii La (Weak (lown seisitiity, ieed of the TEEn

Other examinaton



TEE – to verity LA thrombus presence in case of cardioversion need



Blood samples

o Electrolit K, Na, Mg
o Thyroid hormones/functon IMPORTANT!
o Ph-metry, saturaton
o Holter monitoring

6

o Electrophysiological examinaton

TREATMENT 1

7

8

THERAPY OPTIONS



siius rhythm coiiersioi + thromboembolic preieitoi + maiitaiiiig siius rhythm



cardioiersioi

o electric shock (aiesthesia, traiquilizersn -,> more efectie ii emergeicy

iecessary

o pharmacological



electie



urgeit

o acute cardiac failure, hypoteisioi, shock, ACS

↑ thromboembolic risk

CARDIOVERSION

o shock is syichroiized with the R waie
o not between 80ms before and 30ms afer T wave peak !

o AF 1 x 200 J (50J/100Jn coisecutie with 100 J iicremeits up to 400 J 1 mii break

betweei the coisecutie shots efectieiess 70-,90%

o atrial futer 1 x 50J (trzepotaiie przedsioikwwn
o beter oi fastig (na czczon aid uider geieral aiesthesia

PHARMACOLOGICAL CARDIOVERSION

o < 7 days

o defied efectieiess: dofetylid, fecaiiid, ibutylid, propafeioi, Amiodaroi,

Quiiidiie

o lower efectieiess : Digoxii, Prokaiiamid, Sotalol

o > 7 days

o high efectieiess: dofetylid, Amiodaroi, ibutylid, Quiiidiie, fecaiiamid,

propafeioi,

o lower efectieiess: procaiiamid, sotalol, digoksyia.

Side eaects of antarrhythmic drugs

Drugs for coitrol of AV iode leadiig to decrease of the ieitricular respoise



Betablocekrs,



Calcium chaiiel blockers,



Digoxii

9

AMIODARONE (

PO, IV)

O LOADING DOSE 200 400 MG PER DAY

O MAINTAIN DOSAGE 100-,400 MG

O POTENTIAL ADVERSE EFFECTS: Hypoteisioi, bradycardia, atrioieitricular block, QT

proloigatoi, GI upset, coistpatoin rarely, torsades de poiites, thyroid dysfuictoi,

hepatc toxicity.

QUINIDINE

O LOADING DOSE:

o MAINTAIN DOSAGE: 600-,1500 MG

o ADVERSE EFFECTS: QT, proloigatoi, torsades de poiites, GI upset, hypoteisioi

Cardiac ablaton

is a procedure that cai correct heart rhythm problems (arrhythmiasn.

ardiac ablatoi usually uses loig, fexible tubes (cathetersn iiserted through a ieii or artery
ii your groii aid threaded to your heart to deliier eiergy ii the form of heat or extreme
cold to modify the tssues ii your heart that cause ai arrhythmia.

Cardiac ablatoi is sometmes doie through opei-,heart surgery, but it's ofei doie usiig
catheters, makiig the procedure less iiiasiie aid shorteiiig recoiery tmes.

Decreasing & control HR by drugs

o BB

o CCB (ierapamil, diltazemn

o Digoxii

Digitalis Toxicity:



Bradycardia



heart block



hypoteisioi



HF

RISK OF THROMBOTIC EVENTS



age of the pateit ↑ risk of stroke with AF



Aitthrombotc drugs

10

o Aspirii

ING 2-3

>3 ↑ risk of bleediig

11