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Flashcards in Afib Deck (61):
1

Selection of Agent: No Structural heart disease

First line

dronedarone
flecainide, propafenone, sotalol

2

Selection of Agent: No Structural heart disease

Second Line

amiodarone, Dofetilide

3

IC is contraindicated?

In all Structural heart disease

4

Selection of Agent: Hypertension (no LVH)

First Line

dronedarone
flecainide, propafenone, sotalol

5

Selection of Agent: Hypertension (no LVH)

Second line

amiodarone, dofetilide

6

Hypertension (with LVH)

First line ( only line)

amiodarone

Class IC: Contraindicated

7

Selection of Agent: CAD

First line

Dofetilide
dronedarone
Sotalol

8

Selection of Agent: CAD

Second Line

Amiodarone

9

Selection of Agent: CAD

Contraindication

Class IC

10

Selection of Agent: Heart failure

First Line

Amiodarone, dofetilide

11

Selection of Agent: Heart failure

Contraindication

Class IC
Sotalol
Dronedarone*

12

AF ablation: Potential cure

Indications

Have structurally normal heart

Very symptomatic

Failed at least one antiarrhythmic drug therapy

13

CHADS-2 Scoring System to Predict CVA Risk

Risk Factor Points
CHF 1
Hypertension 1
Age ≥ 75 years 1
Diabetes 1
History of TIA/CVA (Stroke) 2

0 points Use CHADS2-Vasc
≥ 1 point usually requires anticoagulation

14

CHADS-2 Scoring System: What to take

ASA, Nothing or anticoagulation???

CHA2DS2 Vasc
0= Choose nothing or ASA
1= Choose nothing, ASA or anticoagulation
≥2= Anticoagulation

15

Dabigatran

Pradaxa®

16

Rivaroxaban

Eliquis®

17

Edoxaban

Savaysa®

18

Antithrombotic Therapy:
Risk of CVA (stroke)

Factors which increase risk for stroke in pts with AFib


Prior stroke or transient ischemic attack

Age (> 65)

Hypertension

Diabetes Mellitus

Gender (female > male)

EF < 40%

19

Maintenance Antithrombotic Therapy Aspirin or Anticoagulation

Anticoagulation is more effective than ASA for stroke prevention, but has higher bleeding risk and quality of life concerns

20

Maintenance Antithrombotic Therapy Aspirin or Anticoagulation??

Drugs and dosing

Estimate stroke and bleeding risk first then choose:

Oral Anticoagulation Options
Warfarin: Treat to INR 2-3
Dabigatran 150 mg PO BID
Rivaroxaban 20 mg PO Daily with a meal
Apixaban 5 mg PO BID
Edoxaban 60 mg PO Daily
OR
ASA: 81-325mg daily (usually 81 mg)

21

CHADS-2 Scoring System to Predict CVA Risk

Standards

0= Choose nothing or ASA

1= Choose nothing, ASA or anticoagulation

≥2= Anticoagulation

22

CHADS-2 Scoring System to Predict CVA Risk:

Point system

1pt each

CHF
Hypertension
Age ≥ 75 years
Diabetes

History of TIA/CVA 2pts
(Stroke)

23

Anticoagulation Options for Atrial Fibrillation

Warfarin

"Bridge” with UFH or LMWH only in** high risk** patients

Use lower initial UFH dose of 70 units/kg IV push then 15 units/kg/hr and adjust to PTT

May start warfarin monotherapy in low risk patients

24

Apixaban

Eliquis

25

Novel Oral Anticoagulants (NOACs)

Direct Thrombin Inhibitors

Dabigatran (Pradaxa®)

26

Novel Oral Anticoagulants (NOACs)

Direct Xa Inhibitors

Rivaroxaban (Xarelto®)

Apixaban (Eliquis®)

Edoxaban (Savaysa®)

27

Warfarin INR Goal?

2-3

28

Warfarin over 3?

Intracranial bleeding

29

Warfarin under 2?

Ischemic Stroke

30

Benefits of NOACs

Similar or superior efficacy to warfarin

Similar or less bleeding in studies
--Less intracranial hemorrhage

No monitoring needed for efficacy

Rapid onset of action eliminates need for “bridge” therapy

Limited drug-drug interactions

No apparent drug-diet interactions

31

Concerns With NOACs

New agents currently have no test to measure therapeutic effect and no antidote
-Emergency surgery needed?
-Serious bleeding?

Drugs accumulate in renal dysfunction
-Dose reduce and/or avoid use in severe CKD
-Check SCr at least yearly

Non-adherence in clinical practice
-Effects on efficacy?

Cost and Insurance Coverage

32

NOACs: Contraindications


Hemodynamically significant valve disease

CrCl < 15 ml/min or dialysis (doxzyban?)

Dosing adjustments different for each med

Advanced liver disease (increased baseline INR)

33

Antithrombotic therapy:

Initiation: When is anticoagulation appropriate

Always initiate anticoagulation before and after cardioversion (even in ASA patients)

34

Antithrombotic therapy:

Initaiation: When is anticoagulation appropriate?

ASA and Warfarin COMBO??

Warfarin and ASA may be used in combo if patient has embolic event on warfarin alone or compelling indication for both meds

--Combo always increases risk of bleeding
--Newer anticoagulants have increasing data in combo with antiplatelet agents

35

Acute AFIB treatment

HR control
Consider cardioversion
Antithrombotic therapy

36

Chronic AFIB treatment

HR control
Antithrombotic therapy
Consider antiarrhythmic to maintain NSR
Consider ablation

37

Atrial Fibrillation Ablation

Ablation entails destruction of myocardial tissue necessary for the tachycardia “reentry circuit

38

What's the benefit of Ablation therapy?

Potential Cure

39

Ablation indications?

Have structurally normal heart

Very symptomatic

Failed at least one antiarrhythmic drug therapy

40

Should anticoagulation be stopped forAblation?

No data on whether anticoagulation can eventually be stopped

41

Ablation Complications?

Stroke, perforation, pulmonary vein stenosis, death

Recurrence of Afib or Aflutter

Should be performed in experienced centers

42

Permanent Atrial Fibrillation:

May decide NOT to attempt cardioversion

May be unable to maintain sinus rhythm

Long-term management
-Rate Control

-Antithrombotic therapy

43

How long should AFib patient be anticoagulation prior to cardioversion?

3 weeks of anticoagulation prior to cardioversion

or

Anticoagulation with TEE to rule out thrombus

44

How long should AFib patient be anticoagulation after cardioversion?

And for 4 weeks following!!!

45

Whats the restrictions of cardioversion?

All patients with AF > 48 hours must be anticoagulated prior to cardioversion to prevent stroke

46

Prior to elective cardioversion must determine if thrombus has developed in left atrium?

TWO OPTIONS

Transesophageal echocardiogram (TEE)

--->If thrombus present – 3 weeks of anticoagulation, then attempt cardioversion

-->If no thrombus is present – initiate anticoagulant and attempt cardioversion as soon as therapeutic



2. Treat with anticoagulation, in therapeutic range, for at least 3 weeks then attempt cardioversion

-Can use warfarin (INR 2-3), dabigatran, rivaroxaban, apixaban, edoxaban or LMWH (treatment doses)

47

CVA Prevention with Elective Cardioversion.


How long must you coagulate after cardioversion?

Following cardioversion it can take up to 4 weeks for mechanical contraction of the atrium to return to normal, “atrial stunning

Regardless whether a thrombus was present prior to cardioversion, you MUST anticoagulate for 4 weeks following cardioversion

Warfarin (Target INR 2 – 3), dabigatran, rivaroxaban , apixaban, edoxaban or LMWH (treatment doses)

48

Ion Block: IA

Na (intermediate)

49

Ion Block: IC

Na (slow)

50

Ion Block: III

K

51

Meds: IA

quinidine,
procainamide,
disopyramide

52

Meds: IC

propafenone

flecainide

53

Meds: III

amiodarone, dofetilide, ibutilide, sotalol,dronedarone

54

Use for Atrial Fibrillation
IA

Cardioversion and Maintenance NSR

55

Use for Atrial Fibrillation
IC

Cardioversion and Maintenance of NSR

56

Use for Atrial Fibrillation
III

Cardioversion and Maintenance NSR
Ibutilide-Cardiovers
Sotalol-Maintenance

57

Indications for Oral Pharmacologic Cardioversion

Patients with paroxysmal Afib and unbearable symptoms despite rate control

Patients with persistent Afib, and unbearable symptoms, who return to Afib after electrical cardioversion.

-Oral agents have low chance of restoring NSR, may repeat DCC and use meds for maintenance if needed.

58

Who should be Returned to NSR?

People who still feel sick even after rate control.

May try one electrical cardioversion in most persistent Afib patients

Relief of severe symptoms
-->Especially CHF and syncope
Intolerable palpitations

Prevention of cardiac remodeling- a fib alone

59

Why not Cardiovert Everyone Immediately?

Cardioversion and maintenance of NSR has not been shown to improve mortality:

-Electrical and/or pharmacologic cardioversion has risks associated with use (ie proarrhythmia)
Pharmacologic > Electrical

-Anti-arrhythmics decrease AFib burden, may not eliminate Afib and stroke risk – They redcue burden only symtomatic eposoides only

Risk of stroke is highest at time of cardioversion

60

What is Electrical Cardioversion?

Direct current cardioversion (DCC)

Initially preferred over oral meds for persistent Afib due to efficacy and lack of long-term adverse effects

-->Ibutilide can be used instead to avoid anesthesia, but decreased efficacy vs DCC

61

Rhythm Control = Restoring and/or Maintaining NSR

Restore atrial kick.

Restore NSR.

Heart will return to normal beat

Restoration of NSR or Cardioversion:
Electrical: Direct Current Cardioversion (DCC) -DCC-Depolarize whole heart, hope sinus can be re-instated


Pharmacologic alternative: Ibutilide -10 minute infusion??? -Ibutilide is a 10 min infusion that has a high rate of cardioversion (not a s high as DCC), Requires no anesthesia


Restoration AND Maintenance of NSR:
Pharmacologic: Oral antiarrhythmic agents in classes IA, IC and III (sotalol only maintains NSR, does not restore