Thomas Haffey, D.O. FACC,
FACOI, FNLA,
CSOM February, 2015
From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Atrial Tachycardias
Diagram summarizing types of atrial tachycardias often encountered in patients with a history of AF, including those seen after catheter or surgical ablation procedures. P-wave morphologies are shown for common types of atrial flutter; however, the P-wave morphology is not always a reliable guide to the reentry circuit location or the distinction between common atrial flutter and other macroreentrant atrial tachycardias.
*Exceptions to P-wave morphology and rate are common in scarred atria. AF indicates atrial fibrillation; bpm, beats per minute; and ECG, electrocardiogram (72,80).
Causes of Atrial Fibrillation
Ischemic heart disease
Hypertension
Valvular heart disease (esp. mitral stenosis / regurgitation)
Acute infections
Electrolyte disturbance (
hypokalaemia
,
hypomagnesaemia
)
Thyrotoxicosis
Drugs (e.g. sympathomimetics)
Pulmonary embolus
Pericardial disease
Acid‐base disturbance
Pre‐excitation syndromes
Variations
Commonly AF is associated with a
ventricular rate ~ 110 – 160.
AF is often described as having ‘rapid
ventricular response’ once the
ventricular rate is > 100 bpm.
Variations
‘
Slow’ AF is a term often used to describe
AF with a ventricular rate < 60 bpm.
Causes of ‘slow’ AF
include
hypothermia
,
digoxin toxicity
,
medications, and
sinus node
dysfunction
.
Classification
First episode – initial detection of AF regardless of
symptoms or duration
Recurrent AF – More than 2 episodes of AF
Paroxysmal AF – Self terminating episode < 7 days
Persistent AF – Not self terminating, duration > 7 days
Long‐standing persistent AF – > 1 year
Permanent (Accepted) AF – Duration > 1 year in which
Atrial fibrillation is associated with disorganized atrial
contraction and stasis within the left atrial appendage with
associated thrombus formation and risk of embolic stroke.
AF associated with valvular disease has a particularly high
risk of stroke.
Guideline recommendations for stroke prevention and
anticoagulation also include atrial flutter due to the high
likelihood of these patients developing AF.
Risk of Stroke and Anticoagulation
Anticoagulation strategies may include warfarin, aspirin,
clopidogrel and newer agents such as dabigatran.
Anticoagulation guidelines are based on risk of stroke vs. risk
of bleeding.
Stroke risk stratification requires either an assessment of risk
factors or application of a risk score e.g.
CHADS
2
or
CHA
2
DS
2
VASc
.
Risk of bleeding can be estimated by the
HAS BLED
score
From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Mechanisms of AF
AF indicates atrial fibrillation; Ca++, ionized calcium; and RAAS, renin-angiotensin-aldosterone system.
Figure Legend:
From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular AF (Meta-Analysis)
ACTIVE-W indicates Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events-W; AF, atrial fibrillation; AFASAK, Atrial Fibrillation, Aspirin and Anticoagulant Therapy Study; ATAFS, Antithrombotic Therapy in Atrial Fibrillation Study; BAATAF, Boston Area Anticoagulation Trial for Atrial Fibrillation; CAFA, Canadian Atrial Fibrillation Anticoagulation; CI, confidence interval; EAFT, European Atrial Fibrillation Trial; ESPS, European Stroke Prevention Study; JAST, Japan AF Stroke Prevention Trial; LASAF, Low-Dose Aspirin, Stroke, Atrial Fibrillation; NASPEAF, National Study for Prevention of Embolism in Atrial Fibrillation; PATAF, Primary Prevention of Arterial Thromboembolism in Nonrheumatic Atrial Fibrillation; SAFT, Swedish Atrial Fibrillation Trial; SIFA, Studio Italiano Fibrillazione Atriale; SPAF, Stroke Prevention in Atrial Fibrillation Study; SPINAF, Stroke Prevention in Atrial Fibrillation; and UK-TIA, United Kingdom−Transient Ischemic Attack.
Figure Legend:
From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Coagulation Cascade
AT indicates antithrombin and VKAs, vitamin K antagonists.
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Pooled Estimates of Stroke or Systemic Embolism in Patients With AF Treated With Warfarin
ACTIVE W indicates Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events-W; AF, atrial fibrillation; Amadeus, Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation; ARISTOTLE, Apixaban Versus Warfarin in Patients With AF; BAFTA, Birmingham Atrial Fibrillation Treatment of the Aged Study; CI, confidence interval; RE-LY, Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF, Rivaroxaban Versus Warfarin in Nonvalvular Atrial Fibrillation; and SPORTIF, Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation.
Figure Legend:
From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Approach to Selecting Drug Therapy for Ventricular Rate Control∗
*Drugs are listed alphabetically.
†Beta blockers should be instituted following stabilization of patients with decompensated HF. The choice of beta blocker (e.g., cardioselective) depends on the patient’s clinical condition. ‡Digoxin is not usually first-line therapy. It may be combined with a beta blocker and/or a nondihydropyridine calcium channel blocker when ventricular rate control is insufficient and may be useful in patients with HF.
§In part because of concern over its side-effect profile, use of amiodarone for chronic control of ventricular rate should be reserved for patients who do not respond to or are intolerant of beta blockers or nondihydropyridine calcium antagonists.
COPD indicates chronic obstructive pulmonary disease; CV, cardiovascular; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; and LV, left ventricular.
Figure Legend:
From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society
J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022
Strategies for Rhythm Control in Patients With Paroxysmal* and Persistent AF†
*Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation). †Drugs are listed alphabetically.
‡Depending on patient preference when performed in experienced centers.
§Not recommended with severe LVH (wall thickness >1.5 cm).
ǁShould be used with caution in patients at risk for torsades de pointes ventricular tachycardia. ¶Should be combined with AV nodal blocking agents.
