Atrial Fibrillation

Sanchit Turaga

What is AF?
Abnormal ectopic
firing AND/OR
Abnormal re-entry
conduction loops
around the atria
Uncoordinated atrial
beating irregular
ventricular activation
irregularly irregular
pulse

Types of AF
Paroxysmal
Intermittent episodes, self terminate
within 7 days

Persistent:
Terminated by chemical/electrical
cardioversion

Permanent

ECG of AF

ECG characteristics of AF
No P waves
Baseline has irregular fibrillation
waves
Normally shaped but irregular QRS
complex rate (irregularly irregular
pulse)

Symptoms

Palpitations
Breathlessness
Fatigue
May precipitate cardiac failure
Often asymptomatic in older pts
when not associated with ventricular
arrhythmia

Management
Hx/exam, 12 lead ECG, echo, TFTs
Aim: restore sinus rhythm, prevent
recurrent AF, optimise HR during
periods of AF, reduce risk of
thromboembolism, treatment of
underlying cardiac disease

Paroxysmal AF
Usually nothing
1. Beta blockers
2. Class Ic: flecainide (not CAD/LV
dysfunction)
3. Class III: amiodarone/dronedarone
(not in HF/LV impairment)
4. Catheter ablation
1. when drugs ineffective

Persistent + permanent AF
Rate control:
Use treatment to control ventricular rate

Rhythm control
Restore sinus rhythm

Rate control
Maintains heart rate by increasing the amount of AVN
block
Acute + not HF/permanent or persistent AF:
1. Beta blockers (cardioselective) or CCBs not both
at same time
2. Digoxin
If HF:
3. IV Digoxin
4. IV amiodarone
EXCEPTIONAL = PACE AND ABLATE
. catheter ablation of AVN
. Then pacemaker

Rhythm control
Chemical/pharmacological cardioversion
Immediate after administration of IV
heparin if AF<48h
NO structural HD:
1. IV flecainide
Structural/ischaemic HD:
2. IV amiodarone
Same scheme in acute setting/chronic
setting to maintain sinus rhythm

Rhythm control
Electrical/DC cardioversion
for AF>48h
DC shock an alternative and often
effective when drugs fail
Anticoagulate with warfarin before:
INR>2.0 for minimum of 2 weeks before
and continue for 3 months after
Pre-treatment with amiodarone if AF
recurs and DC cardioversion repeated

Preventing
thromboembolism
Loss of atrial contraction stasis of
bloodthrombus in left atrial
appendage
1. Warfarin target INR 2-3
2. NOACs
1.
2.
3.
4.

rivaroXaban factor Xa inhibitors

dabigaTran thrombin inhibitors
Apixaban
No monitoring but no reversal (VitK for
warfarin)

Contraindications to anticoagulation
in AF

BLEEDING
Uncontrolled hypertension
Alcohol misuse
Frequent falls
Poor drug compliance
Drug interactions