Atrial Fibrillation (A-Fib) Summary



Symptoms:

• Palpitations, light-headedness, dizziness, dyspnea, exercise intolerance, chest pain, near-syncope, syncope.



Why?

Cardiac:

	• Valvular heart disease

	• Structural heart disease

	• Decompensated HF

	• New ischemia

Noncardiac:

	• Pulmonary disease

	• Drugs/toxins

	• Metabolic

	• Endocrinopathies



Most Common Sustained Arrhythmia:

• Irregularly irregular ventricular rhythm

• Absence of P waves

• Irregular wide-complex tachycardia: bundle branch block or WPW



Rate Versus Rhythm Control:

Traditionally: No mortality benefit of restoring sinus rhythm vs rate control

Rhythm-control strategy possibly better:

	• Symptom improvement and success with new-onset AF

	• Younger patient age

	• Prevent irreversible structural and electrical remodeling

Older patients with chronic AF: rate control

	• Diltiazem, verapamil, atenolol, metoprolol

	• No benefit of strict versus lenient rate control

Younger patients with symptomatic AF: consider rhythm control (chemical/electrical)

	• Antiarrhythmic drugs

	• Cardioversion

	• Ablation therapy



East-AFNET:

	• Success with rhythm control with early Afib and pts with cardiovascular risk factors



Atrial Fibrillation - Testing:

• TSH level (< 5% pts with afibb)

• Pulse oximetry

• Echocardiography - Evaluate the size of the right and left atria, the size and function of the right and left ventricles; to detect possible valvular heart disease, left ventricular hypertrophy, pericardial disease; assess peak right ventricular pressure and also identify left atrial thrombus

• Digoxin level (if patient is taking it)

• CBC, serum creatinine, test for DM



Atrial Fibrillation: Cardioversion

1. Hemodynamic instability → cardioversion

2. Elective cardioversion - First episode or PAF

• AF ≥48 hours/unknown duration

	• Anticoagulation for 3 weeks before or TEE to exclude thrombus

	• Anticoagulation ≥4 weeks after cardioversion

• "Pill-in-the-pocket" for paroxysmal AF

	• Flecainide or propafenone with β-blocker or CCB



Anticoagulation:

• Initial heparin not typically needed

• DOACs generally preferred

	• Direct thrombin inhibitor (dabigatran)

	• Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban)

• Warfarin: therapeutic INR of 2.0 to 3.0

	• Absolute warfarin indications

		• Moderate or severe mitral stenosis

		• Mechanical heart valve

		• Left atrial occlusion an option if anticoagulation contraindicated



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