Atrial Fibrillation

Current Approaches
to Management

BY: Dr . P. Raveendran
Chief Interventional Cardiologist ,KMC
 Atrial fibrillation
accounts for 1/3 of all 6%
patient discharges PSVT
with arrhythmia as 6%
principal diagnosis. PVCs 18%
Unspecified
4%
Atrial
Flutter

9% 34%
SSS Atrial
Fibrillation

8%
Conduction

Disease 10% VT
3% SCD

2% VF

Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

 Total Hospitalization Days Based on
Presenting Arrhythmia
900
AF
800 Atrial Flutter
Cardiac arrest
700
Conduction disease
600 Junctional
Premature beats
500
Sick sinus syndrome
400 VF

300 VT
Unspecified
200

100

0
Presenting Arrhythmia
Camm AJ. Am J Cardiol. 1996;78(8A):3-11.
 Atrial Fibrillation

 Common and age-dependent

2 - 4% over age 60

 Significant risk of stroke

4% per year (Framingham Study)

 High risk of embolism with cardioversion

 Atrial Fibrillation (AF)

 Chaotic and disorganized atrial activity

 Irregular heartbeat
 Can be paroxysmal, persistent or
permanent (chronic)
 Most common sustained arrhythmia
 Can be symptomatic or asymptomatic
 Incidence increases with age
 Atrial Fibrillation

Conover: Electrocardiography. 4th ed. Mosby 1998; 68.

 Mechanism

 Mechanism:
– Multiple wavelets of reentry
– Ectopic focus
 Induction:
– Rapid atrial pacing
 Termination:
– Pharmacologic therapy
– Cardioversion
– Spontaneous
 ECG Recognition

 Atrial Rate: > 300 bpm

 Rhythm: Irregular
 Ventricular Rate: Variable
– Dependent upon:
• AV node conduction properties
• Sympathetic and parasympathetic tone
• Drugs
 Recognition: Absence of P waves
 ECG Recognition

 Absence of discrete P waves

 Chaotic atrial activity
 Ventricular rate irregular
 ECG Recognition

ECG used with permission of Texas Cardiac Arrhythmia, P.A.

 Other Characteristics

 Lost atrial kick and decreased filling times can result in

congestive heart failure
 Ventricular rates < 100 bpm suggest AV conduction
disease
 Irregular ventricular rhythm > 180 bpm
– Suggest an accessory pathway (broad QRS)
– Enhanced AV nodal conduction (narrow QRS)
 Tachycardia-Induced Tachycardia

 One tachycardia degenerates into another

 Examples:
– Atrial flutter and atrial tachycardia into AF
– AV node reentry and AV reentry into AF
– Ventricular tachycardia into VF
 Treating the initiating tachycardia can help prevent
future episodes of AF an VF
Atrial Fibrillation: Causes

 Cardiac
 Non-cardiac
 “Lone” atrial fibrillation
Atrial Fibrillation: Cardiac Causes
 Hypertensive heart disease
 Ischemic heart disease
 Valvular heart disease
– Rheumatic: mitral stenosis
– Non-rheumatic: aortic stenosis, mitral regurgitation
 Pericarditis
 Cardiac tumors: atrial myxoma
 Sick sinus syndrome
 Cardiomyopathy
– Hypertrophic
– Idiopathic dilated (? cause vs. effect)
 Post-coronary bypass surgery
Atrial Fibrillation: Non-Cardiac Causes

 Pulmonary
– COPD
– Pneumonia
– Pulmonary embolism
 Metabolic
– Thyroid disease: hyperthyroidism
– Electrolyte disorder
 Toxic: alcohol (‘holiday heart’ syndrome)
 “Lone” Atrial Fibrillation

 Absence of identifiable cardiovascular, pulmonary, or associated systemic

disease

 Approximately 0.8 - 2.0% of patients with atrial fibrillation (Framingham

Study)1

 In one series of patients undergoing electrical cardioversion, 10% had

lone AF.2

1
Brand FN. JAMA. 1985;254(24):3449-3453.
2
Van Gelder IC. Am J Cardiol. 1991;68:41-46.
 Atrial Fibrillation: Clinical Problems
 Embolism and stroke (presumably due to LA clot)
 Acute hospitalization with onset of symptoms
 Anticoagulation, especially in older patients (> 75 yr.)
 Congestive heart failure
– Loss of AV synchrony
– Loss of atrial “kick”
– Rate-related cardiomyopathy due to rapid ventricular response

 Rate-related atrial myopathy and dilatation

 Chronic symptoms and reduced sense of well-being
 Atrial Fibrillation and Stroke

 Risk: 5 - 8% per year in high-risk patients

 Anticoagulant therapy is clearly indicated and

beneficial in rheumatic atrial fibrillation.

 In non-rheumatic atrial fibrillation, major

randomized trials have provided useful
guidelines for identifying and treating patients
at risk.
 Treatment Options

 Restoration/maintenance of sinus rhythm

– Pharmacologic therapy
– Surgery (Maze procedure)
– Catheter ablation
– Atrial pacing
– Device therapy
– Cardioversion
 Treatment Options

 Rate control during AF

– Pharmacologic therapy
– Catheter ablation
• AV junction ablation (ablate and pace)
• AV nodal modification
 Prevention of thromboembolism
– Pharmacologic therapy
• Warfarin
• Aspirin
Major Clinical Trials in Atrial Fibrillation
 SPAF1 Stroke Prevention in Atrial Fibrillation
 BAATAF2 Boston Area Anticoagulation Trial for
Atrial Fibrillation
 CAFA3 Canadian Atrial Fibrillation Anticoagulation
 AFASAK4 Copenhagen Investigators
 SPINAF5 Stroke Prevention in Nonrheumatic
Atrial Fibrillation

1
Circulation. 1991;84:527-539. 4
The Lancet. 1989;1:175-178.
2
N Engl J Med. 1990;323:1505-1511. 5
N Eng J Med. 1992;327:1406-1412.
3
J Am Coll Cardiol. 1991;18:349-355.
 SPAF BAATAF CAFA AFASAK SPINAF

Number of Patients 1330 420 378 1007 571

Drug Used Warfarin ASA Warfarin Warfarin Wafarin ASA Warfarin

(INR 2-4.5) 325 mg (PT 1.2-1.5x (INR 2-3) (INR 2.8-4.2) 75 mg (INR 1.2-1.5)
Control)

Embolic Rate (%)

Treatment 2.3 3.6 0.41 3.5 1.5 6.0 4.3
Control 7.4 6.3 2.98 5.2 6.2 6.2 0.9

Risk Reduction (%)

(95% confidence) 67 42 86 45 — — 79

Major Bleeding
Complications (%)
Treatment 1.5 1.4 0.9 2.5 6.3 0.6 1.5
Control 1.6 1.9 0.5 0.5 0.0 0.0 0.9
 Predictors of Thromboembolic Risk in
Atrial Fibrillation

 History of hypertension

 Prior stroke or TIA

 Diabetes

 Recent heart failure

 Age > 65 years

Atrial Fibrillation Investigators. Arch Intern Med. 1994;154:1449-1457.
 SPAF III

 SPAF III study evaluated the benefit of

adjusted-dose warfarin vs. low-intensity, fixed-dose
warfarin (INR 1.2 - 1.5) plus ASA
in high-risk patients with atrial fibrillation.

SPAF Investigators. Lancet. 1996;348:633-638.

 Relative Risk of Adjusted-Dose Warfarin and Combination Therapy
16

14
Intracranial hemorrhage
Event rate (% per year)

12 Disabling ischemic stroke

10 Non-disabling ischemic stroke

8
p = 0.007 p = 0.002
6
4

0
Adjusted-dose Combination Adjusted-dose Combination
warfarin therapy warfarin therapy

No previous thromboembolism Previous thromboembolism

SPAF Investigators. Lancet. 1996;348:633-638.
 20
Relative Risk of

Annual event rate (95% CI)

Adjusted-Dose Combination therapy
Warfarin and 15
Adjusted-dose warfarin
Combination
Therapy 10

0
<1.2 1.2-1.5 1.5-1.9 1.9-2.4 >2.5
INR

Event rates for ischemic stroke or systemic

embolism at start of follow-up

SPAF Investigators. Lancet. 1996;348:633-638.

 Recommendations Regarding
Anticoagulation for Atrial Fibrillation
Clinical Background Treatment
 Rheumatic heart disease,  Warfarin (INR 2.0 - 3.0)
age < 75 yr.
 “Lone” atrial fibrillation,
age < 65 yr.
 ASA 325 mg/day
 High risk, age < 75 yr.
 Warfarin (INR 2.0 - 3.0)
 High risk, age > 75 yr.
 Warfarin (INR 1.5 - 2.5)
 Patients with major contraindications
to warfarin:  ASA 325 mg/day
– Intracranial hemorrhage
– Unstable gait/falls/syncope
– Poor compliance
 Guidelines Regarding Anticoagulation
for Atrial Fibrillation
Clinical Background Treatment
 Elective cardioversion  Warfarin (INR 2.0 - 3.0) 4 wks. before
and 4 wks. after cardioversion
 Elective surgery for
anticoagulated patient:

– Minor surgery – Hold warfarin for 3 days

– Major surgery – Stop warfarin 7 days prior to surgery

Daily INR when < 1.5

Start SQ heparin 10,000u every 12
hours and follow PT/PTT
Stop heparin 12 hours before
surgery
 Current Recommendations for
Anticoagulation Therapy
for Atrial Fibrillation
 INR 2.0 - 3.0 for appropriate patients1,2

or

 Warfarin (INR 2.0 - 3.0) or ASA 325 mg/day

in patients without clinical or
echocardiographic risk factors

1
Blackshear JL. Mayo Clin Proc. 1996;71:150-160.
2
Hylek EM. N Eng J Med. 1996;335:540-546.
 Echocardiographic Risk Factors
for Stroke Factors in Patients with
Atrial Fibrillation

 LV systolic dysfunction

 Increased LA size

SPAF Investigators. Ann Intern Med. 1992;116:6-12.

 Role of Echo in Atrial Fibrillation

 Identify structural heart disease

 Identify LVH

 Identify LA size

 Detect “smoke”

 Detect clot in LA
 Role of TEE in Atrial Fibrillation

 Transesophageal echo is more sensitive (92%)

and specific (98%) for detecting left atrial clot.

 Thromboembolic event is presumably due to left

atrial clot.

 Most clots are in left atrial appendage but poorly

visualized by transthoracic surface echo.

Manning WJ. N Engl J Med. 1993;328:750-755.

A Left Atrium B Left Atrial Appendage Clot

Manning WJ. N Engl J Med. 1993;328:750-755.

 Rationale for Precardioversion TEE

 Absence of clot on TEE may obviate need

for anticoagulation.

 Avoiding delay necessary for prolonged

anticoagulation prior to cardioversion
increases likelihood of successful
cardioversion and maintenance of normal
sinus rhythm.
 Increase in Spontaneous Echo Contrast
(“Smoke”) Following Electrical Cardioversion

Left atrial appendage (LAA) before (A) and after (B) cardioversion

Grimm RA. J Am Coll Cardiol. 1993;22(5):1359-1366.

 Precardioversion TEE

 ACUTE: Assessment of Cardioversion

Using Transesophageal
Echocardiography.

 Large-scale randomized clinical trials

on the role of precardioversion TEE are
still pending.
 Timing of Cardioversion for
Atrial Fibrillation
 Chronic
1 month coumadin  cardioversion (CV)

 Uncertain duration
Stable  1 month coumadin  CV
Unstable  TEE  CV

 Acute
no clot
CV  coumadin
Heparin  TEE
coumadin  repeat TEE  CV
clot
 Therapeutic Approaches to
Atrial Fibrillation
 Anticoagulation
 Antiarrhythmic suppression
 Control of ventricular response
– Pharmacologic

– Catheter modification/ablation of AV node

 Curative procedures
– Surgery (maze)

– Catheter ablation
 Length of time
in AF prior to
Atrial cardioversion

Fibrillation 100 < 3 Months

3 - 12 Months
> 12 Months
 Duration of atrial

Patients in sinus rhythm (%)

80
fibrillation may
predict likelihood
60
of remaining in
normal sinus
rhythm after 40
*
cardioversion
20

0
*P = <0.02 Initial One month Six months
post-CV post-CV

Dittrich HC. Am J Cardiol. 1989;63:193-197.

 Control of Ventricular Rate in
Atrial Fibrillation

 Digoxin

 Calcium channel blockers

Verapamil, diltiazem

 Beta blockers
 Antiarrhythmic Drugs to Suppress
Atrial Fibrillation

 Class I agents
– IA: quinidine, procainamide, disopyramide
– IC: flecainide, propafenone

 Class III agents

– amiodarone, sotalol
Medication for Rate Control in Atrial Fibrillation
Oral
Immediate maintenance
Agent Action IV dose therapy Avoid use in
Digoxin Cardiac 0.5 mg + 0.125-0.5 mg/day; WPW, HCM
glycoside 0.25 mg in 4-6 h + renal
0.25 mg in 4-6 h

Diltiazem Calcium 20 mg (or 25-35 120-360 mg/day; WPW, constipation,

channel mg/kg) over 2 min hepatic peripheral edema,
blocker + 2nd bolus CHF allowed after 20 min + 5, 10,
15 mg/h infusion

Verapamil Calcium 5-10 mg every 120-240 mg/day; Same as diltiazem,

channel 30 min or 5 mg/h hepatic risks with CHF blocker possibly
greater

Adapted from Blackshear JL. Mayo Clin Proc. 1996;71:150-160.

Medication for Rate Control in Atrial Fibrillation

Oral
Immediate maintenance
Agent Action IV dose therapy Avoid use in

Propranolol ß-blocker 0.5-1.0 mg every 40-320 mg/day; Bronchospastic

5 min up to 5 mg hepatic lung disease,
total CHF

Metoprolol ß-blocker 5 mg every 5 min 50-200 mg/day; Same as

up to 15 mg total hepatic propranolol

Esmolol ß-blocker 0.5 mg/kg/min None Same as

load over 1 min propranolol
+ 0.05-0.3 mg/
kg/min

Adapted from Blackshear JL. Mayo Clin Proc. 1996;71:150-160.

 Medication for Rhythm Control in
Atrial Fibrillation
Drug Oral Dose Useful in Avoid in
Class IA
Quinidine gluconate 324-648 mg Q 8-12 hr Chronic renal failure CHF, liver failure
Procainamide 0.5-1.5 g Q 12 hr* Men, short-term therapy Renal failure, CHF,
joint disease
Disopyramide 200-400 mg Q 12 hr Women Older men at risk for
urinary retention, CHF,
glaucoma, renal failure

Class IC
Flecainide 75-150 mg Q 12 hr Failure of Class IA drugs CHF, CAD
Propafenone 150-300 mg Q 8 hr Failure of Class IA drugs CHF

Class III
Sotalol 80-240 mg Q 12 hr
Amiodarone 1200 mg QD for 5 days
followed by 400 mg QD for
1 month, then 200-400 mg QD
Many alternative dosing
regimens
Failure of IA or IC drug Where beta blockade is
May be used with mild- contraindicated
moderate LV dysfunction
Severe LV dysfunction, Young patients,
failure of other drugs, pulmonary disease
CHF, renal failure

* For newer preparation.

Adapted from Gilligan DM. Am J Med. 1996;101:413-421.
Recommendations for Management of Atrial Fibrillation < 48 Hours

Atrial Fibrillation < 48 hours

Control ventricular rate

Consider antithrombotic therapy
Observe for spontaneous
conversion

Prompt electrical or
pharmacologic
conversion

Antiarrhythmic therapy No antiarrhythmic therapy

if if
Unstable hemodynamics Stable hemodynamics,
or frequent recurrences infrequent
recurrences, or first
Adapted from Golzari H. Ann Intern Med. 1996;125:311-323. episode
Recommendations for Management of Atrial Fibrillation > 48 Hours
Atrial Fibrillation > 48 Hours

Control ventricular rate

Start antithrombotic therapy
(heparin and/or warfarin or aspirin)
Duration < 1 year Duration > 1 year
or
Warfarin therapy 3-4 weeks

Cardioversion or pharmacologic conversion

Antiarrhythmic therapy No antiarrhythmic therapy

if if
Stable hemodynamics,
Unstable hemodynamics infrequent recurrences, or
or frequent recurrences
first episode
Chronic antithrombotic
Continue warfarin 1-2 months therapy
Monitor for recurrences Assure control of
Adapted from Golzari H. Ann Intern Med. 1996;125:311-323. ventricular rate
 Antiarrhythmic Therapy for Atrial
Fibrillation

 Advantages  Disadvantages

– High efficacy for some – High recurrence rate

patients, at least
initially – High long-term cost
(< 50% of all patients)
– Noncurative
– Low initial cost
– Adverse effects
– Noninvasive
– Potential proarrhythmia
 Rate Control for Atrial Fibrillation

 Some “idiopathic” cardiomyopathies are due to

atrial fibrillation with rapid ventricular response.
When rate control is achieved, LV function often
improves dramatically.

 In some patients, pharmacologic therapy is

ineffective for rate control, and catheter ablation and
permanent pacing are indicated.
 Case Study
60
52 Improved EF of
48
36-year-old male
40 who presented with
AF (HR 140 bpm)
EF (%)

30 29
1 week prior to
20 initial echo

0
Initial 4 days 2 months 8 months
Heart rate AF 75* SR 80 SR 80 SR 60
(bpm)
Primary Rx: DC cardioversion
* Heart rate 140 one week earlier
Other Rx: digoxin and quinidine
Grogan M. Am J Cardiol. 1992;69:1570-1573.
 Case Study

60 60 Improved EF in
60 80-year-old female
with chronic AF
40 but with improved
40 rate control
30
EF (%)

20

0
Initial 1 month 4 months 8 months
Heart rate AF 120 AF 70 AF 76 AF 70
(bpm)
Primary Rx: digoxin and propranolol
Grogan M. Am J Cardiol. 1992;69:1570-1573.
 Case Study
61 Markedly improved EF
60 in 55-year-old female
52 with both rate control
& NSR, with reversion
to AF (HR 140 bpm)
40 and subsequent
decrease in EF
EF (%)

20 20
20

0
Initial 3 months 51 months 56 months
Heart rate AF 150 AF 75 AF 140 SR 80
(bpm) Primary Rx: amiodarone
Grogan M. Am J Cardiol. 1992;69:1570-1573. Other Rx: digoxin and lisinopril
AV Nodal Modification by Intracardiac Ablation

RAO LAO
Catheter Ablation of AV Nodal Conduction
and Permanent Pacemaker Implantation

 Treatment for patients with atrial

fibrillation with a rapid ventricular
response
 Maze Procedure

 Concept involves open heart surgery on the atria to

restore sinus rhythm and prevent AF
 Multiple atrial incisions are made to direct sinus
impulses through a path or a “maze” to reach the AV
node
 This “maze” compartmentalizes the atria utilizing scar
tissue
 Approximately 5% require permanent pacemaker post-
op
 Atrial
Fibrillation
Curative
Procedures:
Surgical Maze

Kawaguchi AT. J Am Coll Cardiol. 1996;28:985-990.

 Efficacy of
100
Surgical Maze Maze

Freedom from atrial fibrillation (%)

Procedure for 90
Atrial Fibrillation 80

70
60

50

40
30

20 Control
10

0
0 1 2 3
Post-op years

Kawaguchi AT. J Am Coll Cardiol. 1996;28:985-990.

 Catheter Maze
Procedure for
Atrial Fibrillation

Haïssaguerre M. J Cardiovasc Electrophysiol.

1994;5:1045-1052.
 RF Ablation

 Maintenance of sinus rhythm:

– Endocardial linear lesions are made to
compartmentalize the atria creating a maze-like result
 Rate control:
– AV node ablation (ablate and pace)
• Catheter ablation of the AV junction that results in complete heart
block
– AV node modification
• Catheter ablation on the AV node (slow pathway) to prevent rapid
ventricular rates
 AV Junction Ablation

 Indications:
– Permanent, symptomatic atrial fibrillation
– Suppression of AV node conduction
• Paroxysmal atrial fibrillation
• Atrial tachycardia
• Atrial flutter
 AV Junction Ablation

 AVJ ablation (ablate and pace)

– Right and left sided catheter approaches utilized
– Creates complete heart block (CHB)
– Permanent pacing is required
– Warfarin therapy is indicated
 AV Junction Ablation

Singer: Interventional Electrophysiology. Williams & Wilkins 1997; 328.

 AV Node Modification

 Indications:
– Suppression of AV node conduction
• Atrial fibrillation
• Atrial tachycardia
• Atrial flutter
 May prevent need for permanent pacing
 Modify AV node conduction
 Ablation of slow pathway potentials
 Atrial Fibrillation: Areas of Research
 AFFIRM study
– National Heart Institutes atrial fibrillation study
– Heart rate control and anticoagulation vs. rhythm control with
antiarrhythmic drugs
 Patient-activated or automatic atrial defibrillator
 Dual-site and biatrial pacing
 Atrial pacing therapies for AF prevention
 Catheter ablation therapies for AF
– Catheter “maze” procedure
– Ablation for “focal” AF
Permanent Pacing and Atrial Fibrillation:
Findings

With Atrial Pacing:

 Less atrial fibrillation
 Less thromboembolic risk
 Less incidence of AV block

Andersen HR. Lancet. 1994;344:1523-1528.

 Incidence of Chronic Atrial Fibrillation in Patients
Randomized to Atrial & Ventricular Pacing
50

Atrial
Chronic atrial fibrillation (%)

40 Ventricular

30

20

10

0
3 months 1 2 3 4 5
Years after implantation
Andersen HR. Lancet. 1994;344:1523-1528.
 Incidence of Thromboembolic Events in Patients
Randomized to Atrial or Ventricular Pacing
25

20 Ventricular
Number of patients

15

10

Atrial
5

0
0 3 months 1 2 3 4 5 6
Years after implantation
Andersen HR. Lancet. 1994;344:1523-1528.
 Permanent Pacing for Prevention of
Atrial Fibrillation
 Evidence that AAI pacing is associated
with less atrial fibrillation than VVI pacing.1
 Chronic dual-site right atrial pacing may
also prevent recurrent atrial fibrillation.2

1
Andersen HR. Lancet. 1994;344:1523-1528.
2
Saksena S. J Am Coll Cardiol. 1996;28(3);687-694.
 CXRs of Pacemaker with Dual-Site Atrial Pacing and
Single Ventricular Lead

Courtesy of Dr. Sanjeev Saksena

 Permanent Pacing for Prevention of AF:
Results

 Marked decline in AF recurrence with

atrial pacing
 With dual-site pacing & optimal drug
regimen, no AF recurrence
 With single-site pacing, 5 recurrences in
12 patients

Saksena S. J Am Coll Cardiol. 1996;28(3);687-694.

 Permanent Pacing for Prevention of AF:
Results

 Mean arrhythmia-free interval increased

from 14 days before pacing to 89 days
(dual-site) & 76 days (single-site) after
pacing.
 Mean antiarrhythmic drug use declined
from 4 drugs before pacing to 1.5 drugs
after pacing.

Saksena S. J Am Coll Cardiol. 1996;28(3);687-694.

 Mean Arrhythmia-Free Intervals
Days Preimplantation period
120
Dual-site pacing
p = 0.10
High right atrial pacing
100
89

80 76

P < 0.001
60

40

20 14

0
Saksena S. J Am Coll Cardiol. 1996;28(3);687-694.
 Number of Symptomatic Episodes Before and After
Initiation of Pacing
Episodes per Week
7 Preimplantation period
Dual-site pacing
6 High right atrial pacing

4 p = 0.09

2 p – NS

0
Saksena S. J Am Coll Cardiol. 1996;28(3);687-694.
 Mean Number of Antiarrhythmic Drugs Before and After
Initiation of Pacing
# Drugs Before Pacing After Pacing
7
Drugs of all classes
Class I and III
6

5 p < .001

4
p < .005

0
Saksena S. J Am Coll Cardiol. 1996;28(3);687-694.
 Transvenous Atrial Defibrillation

 Prospective multicenter trial to define

efficacy and safety of low-energy shocks
for atrial defibrillation
 Delivery of shocks between right atrial and
coronary sinus electrode catheters
 141 patients enrolled

Levy S. J Am Coll Cardiol. 1997;29:750-755.

 Catheter Position for Intracardiac Atrial Defibrillation

Levy S. J Am Coll Cardiol. 1997;29:750-755.

 Atrial Defibrillation: Conclusions

 Atrial defibrillation using transvenous

intracardiac leads can be highly efficacious and
requires relatively low energies.
 The optimal waveform characteristics of
delivered energy to minimize patient discomfort
during defibrillation continues to be evaluated.

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