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 #Atrial #Fibrillation #AFib #diagnosis #management #cardiology
