34 - AFIB Supraventricular

Question 1

AFib Risk Factors

Answer 1

Extracardiac Factors:
HTN / Obesity / OSA / Alcohol+Drugs
HYPERthyroidism

• *Genetic Varients**
• *Channelopathy** / Cardiopathy

Atrial Structural Abnormalities:
Fibrosis / Ischemia / HYPERtrophy
DIlation / Infiltration

Question 2

4 Different AFib Classifications

Answer 2

• *PAF = Paroxysmal AF**
• *Terminates sponaneously** or w/ interventin withn < 7 days

Persistant AF
Continuous and sustained > 7 days

Long Standing Persistant AF” > 12 MONTHS

Permanant / Chronic AF
Patient + Provider DECIDE TO STOP / Maintain NSR
allow them to STAY AFIB, no more rhythm control

Question 3

Complications of AFib

Answer 3

Thromboembolic Risk
5x increase stroke risk

• *HEART FAILURE**
• *Tachycardia-induced Cardiomyopathy** - chicken-egg?
• *Impaired diastolic Filling**
• LOSS of* Atrial Kick

Question 4

S/Sx of AFib

Answer 4

• *400-600**
• *ATRIAL BPM**

Sxs:

• ASYMPTOMATIC*
• *Dizziness / SOB / Fatigue / Palpitations**

Question 5

Indications for
RATE CONTROL
Slowing down the Ventricular Response
allow them to STAY in AFIB

Answer 5

_*Minimal or NO*
SYMPTOMS_

Treatment of choice for:

• *PERSISTANT_ or _PERMANENT**
• *AFIB**

we are NO LONGER trying to PURSUE NORMAL RHYTHM

Question 6

RATE CONTROL
Slowing down the Ventricular Response
allow them to STAY in AFIB

TREATMENT OPTIONS

Answer 6

+ANTICOAGULATION+

AV NODAL ABLATION
with pacemaker

Beta Blockers

Non-DHP CCBs
Verapamil + Diltiazem

Digoxen

AMIODARONE
last line - lot of ADRs

Question 7

RATE CONTROL
For ASx / Persistant or Permaning AFIB

HEART RATE GOAL

Answer 7

<110 BPM
for ASx patients + Normal LV Fxn

<80 BPM
for SYMPTOMATIC patients

Question 8

RHYTHM CONTROL
Attempt to ELIMINATE the AFIB

INDICATIONS

Answer 8

PAROXYMAL** or **Persistant Afib

SYMPTOMATIC** / **Hemodynamically Unstable
despite adequate RATE control

Exacerbating Heart Failure

Other factors that favor Rhythm > Rate:

• *Younger Age** / First episode of AF
• *Tachycardia-mediated cardiomyopathy**

Question 9

• *RHYTHM CONTROL**
• *TREATMENT OPTIONS**

Answer 9

Direct Current CARDIOVERSION
quick / effective + anesthesia
might not need drug after

• *PVI = Pulmonary Vein Isolation ABLATION**
• *1st line for Paroxysmal AFIB**
• *DRUGS**
• less EFFECTIVE, but with side effects*
• *Depends on HEART DISEASE or NOT**

Question 10

RHYTHM CONTROL

• *DRUG OPTIONS**
• No Structural Heart Disease*

Answer 10

Ultimately ANY option is fine

• *ABLATION**
• *1st line if Paroxysmal AF**
• *Dofetalide_ / _Sotalol**
• caution in those @ risk for TDP* & NOT for severe LVH​

Dronedarone

• *Propafenone_ / _Flecanide**
• combine with AV nodal blocking agents & NOT for severe LVH*
• AMIODARONE*
• last line due to ADR*

Question 11

RHYTHM CONTROL

• *DRUG OPTIONS**
• *Structural Heart Disease = CAD**

Answer 11

• *ABLATION**
• *1st line if Paroxysmal AF**
• *Dofetalide_ / _Sotalol**
• caution in those @ risk for TDP* & NOT for severe LVH

Dronedarone

• AMIODARONE*
• last line due to ADR*

no Propafenone or Flecanide for CAD or HF

Question 12

RHYTHM CONTROL

• *DRUG OPTIONS**
• *Structural Heart Disease = HF**

Answer 12

• *ABLATION**
• *1st line if Paroxysmal AF**
• Dofetalide** / *no sotolol
• caution in those @ risk for TDP* & NOT for severe LVH
• *AMIODARONE**
• HF only one where AMIO is first line*

no Propafenone or Flecanide for CAD or HF

Question 13

Which Rhythm Control Drugs:

NOT recommended for Severe LVH >1.5cm?

Answer 13

FLECAINIDE** + **PROPAFANONE

also: need to be combined with AV nodal blocking agents

also not indicated for CAD or HF

Question 14

Which Rhythm Control Drugs:

CAUTION IN PTS AT RISK FOR TORSADES?

Answer 14

DOFETILIDE** + **FLECAINIDE

SOTOLOL

• dronaderone + amiodarone*
• still @ risk, but LOW risk*

Question 15

CHADS VASC
DEFINITIONS

Answer 15

Congestive Heart Failure

History of HTN

A₂ge >75 y/o

Diabetes

_S₂_troke - previous ischemic stroke

• V*ascular Disease:
• *MI / Previous CABG / PAD**

Age 65-74 y/o

Sc - Female Sex

Question 16

CHA₂DS₂ VASc

HIGH RISK

Answer 16

> 2 Risk Factors
OR
Singular risk factor:
Prior Ischemic Stroke / TIA / Systemic Embolism
MECHANICAL HEART VALVE
Age > 75 y/o

Question 17

AFIB** + **ACS w/ Stenting

TRIPLE THERAPY Recommendations

Answer 17

CLOPIDOGREL > prasugrel

Consider transitioning to:
Double Therapy @ 4-6 weeks

Double Therapy:

• *P2Y12 + VKA** - reasonable
• *Clopidogrel + Dabigatran 150mg** - reasonable
• *Clopidogrel + Rivaroxaban 15mg** - maybe reasonable

Question 18

• *WATCHMAN**
• *Left Atrial Appendage Occlusion**

USE / FUNCTION

Answer 18

CATCHES THE EMBOLISM

Used if:
can NOT be on Long Term AC
+
High Risk for Bleed

Question 19

Afib** with **CARDIOVERSION

AF Onset < 48 hours

NOPE

Answer 19

Conventional OAC** or **TEE

3 Weeks of Conventional OAC
VVV
then continue with: CARDIOVERSION
VVV
4 WEEKS OF AC
unless…
CHADSVASC HIGH RISK –> LONG TERM OAC

Question 20

Afib** with **CARDIOVERSION

AF Onset < 48 hours

YES

Answer 20

• *AC w/ HEPARIN**
• *only if Intermediate risk +**
• *>1** for men or >2 for women
• if NOT* –> continue with:
• *CARDIOVERSION**
• *4 Weeks of AC AFTER if:**
• *SR w/ Risk Factors** OR AFib