Fibs and Flutters: The Heart of the Matter Anita Ralstin, CNP By - PDF document

4/7/13 Fibs and Flutters: The Heart of the Matter Anita Ralstin, CNP By the Numbers  Atrial Fibrillation Hospital Discharges /quarter for 2012 -- 116,500  Average Length of Stay – 4 days  Projected that 20% of those over 80 years have atrial fibrillation  Prevalence: 2,000,000 US 1

4/7/13 What is Atrial Fibrillation? 2

4/7/13 What is Atrial Fibrillation?  An irregular heart beat generated when the top chambers of the heart are beating very rapidly.  Atrial fibrillation compromises several aspects of heart function.  Rate  Regularity of the heart rhythm  Loss of loading the ventricle with blood  Loss of the forceful atrial contraction slows blood flow in the top chambers of the heart. Are there different kinds?  Paroxysmal (self-terminating)- sustained > 30 seconds  Persistent (>7d)- requires shock to terminate  Permanent- unable to convert except with surgery or ablation  First detected episode vs. recurrent  Secondary AF- pneumonia, heart surgery etc.  Lone AF- no other heart disease 3

4/7/13 What causes Atrial Fibrillation? Triggers for Atrial fibrillation Triggers  Pulmonary veins  Account for ~70% of atrial fibrillation in men  60% in women  Ganglionated plexi 20%  Other thoracic veins 10% in both sexes  Nonvenous locations  LA Posterior wall, CS OS, Crista Terminalis  Triggers elimination is curative. 4

4/7/13 Case 1  58 year old woman  History of symptomatic bradycardia and PPM  Device check shows 2 episodes of atrial fibrillation with ventricular rate to 188, longest duration; 2 hours 14 minutes  Patient is asymptomatic  History includes hypertension  Current medication: Micardis  Echo and stress of 1/2013 WNL 5

4/7/13 Goals of Therapy  Prevent Stroke- appropriate anticoagulation  Prevent CHF- rate control, HTN control  Acute symptomatic CHF related to rate  Chronic diastolic CHF in older patients  Control symptoms What symptoms come from Atrial Fibrillation?  Palpitations, chest pain  Fatigue  Shortness of breath with exertion  Leg swelling  Difficulty concentrating  Difficulty sleeping  Lightheadedness with change of position  Fainting 6

4/7/13 Case 1  Type of atrial fibrillation?  New onset, paroxysmal  Concerns about rate or rhythm?  HR of 188  Yet to determine burden  What is her stroke risk? Replacing the CHADS2 score  CHADS2 score- not everyone needs warfarin  2 points for prior stroke  1 point for congestive heart failure, high blood pressure, age >75 and diabetes. • In most series 25-35% of the patients are in the indeterminate range • Are low risk patients low risk? 2006 ACC/AHA Guidelines for atrial fibrillation management 7

4/7/13 CHA 2 DS 2 Vasc Score  Congestive Heart Failure  Hypertension  Age>75 (2 points)  DMII  Prior Stroke (2 points)  Age 65-74  Vascular disease (PVDz, aortic atheroma)  Female Sex CHADS vs. CHA 2 DS 2 VASc  121,281 patients with nonvalvular Afib  The critical area is the in the low and intermediate risk patients * * Oleson, JB et al, BMJ online first December 2010 :1-9. 8

4/7/13 CHA 2 DS 2 VASc is Superior  Low risk CHADS2= 39% intermediate risk, 21% high risk (only 40% were “ low risk) by CHA 2 DS 2 VASc  Intermedite CHADS2=93% at high risk  CHA 2 DS 2 VASc not only predicted TE better but also mortality better  C statistics for the low, intermediate and high for CHA 2 DS 2 VASc were much better.  CHA 2 DS 2 VASc =0 no anticoagulation Oleson, JB et al, BMJ online first December 2010 :1-9. Case 1  What is her need for anticoagulation  CHADS2 score = 1 (HTN)  CHADS2Vasc = 2 (HTN and Gender)  Also consider burden  3 hours or more when identified on device 9

4/7/13 Case 1 Plan  Patient education  What is atrial fibrillation  Monitor for symptoms  Address anxiety  Rate Management  Beta blocker, calcium channel blocker or digoxin  Consider ejection fraction and side effects  Anticoagulation:  ASA 81 mg – 162 mg (chewable) Will it get worse?  Lone Atrial Fibrillation- rare  No evidence that it will progress  Paroxysmal atrial fibrillation  15%/year progress to persistent atrial fibrillation  More heart disease means more likely to progress  Progression generally means more symptoms  Older, sicker patients move towards more atrial fibrillation. 10

4/7/13 Case 2  60 year old male  New onset atrial fibrillation with shoulder surgery  Onset documented with hospitalization.  Symptomatic with rapid ventricular rate (RVR): hypotensive  PMH  Hypertension  Gout  Barrets Esophagus  Smoker  Obese Atrial Scarring  Injury to the heart muscle  Age  High blood pressure  Structural problems in the heart  Heart attacks, valve problems, congestive heart failure  Sleep apnea  Obesity  Alcohol  Repeated exercise  All of these lead to fibrosis 11

4/7/13 Case 2 Diagnostic  Echocardiogram: Normal EF, Moderate left atrial enlargement  Lab work: no significant abnormals Case 2 Hospital Treatment  EP consult  Rate control  Diltiazem drip  Hypotension  IV metoprolol  Short acting  Digoxin load  Consider renal function 12

4/7/13 Case 2 Contd  Rhythm Control: Hospital  If unstable and known duration of <48 hours  Synchronized cardioversion  If unstable and unknown duration  TEE and cardioversion  Antiarrhythmic  Amiodarone drip to PO Case 2 Still in the Hospital  Anticoagulation  CHADS Vas score = 1 (HTN)  Heparin to warfarin initiated  Cardioversion results in atrial stunning and increases risk of thrombus early post CV 13

4/7/13 Case 2 Office Visit  Presented complaining of fatigue, irregular HR, generally not feeling well  ECG shows recurrent atrial fibrillation, rate 95 on diltiazem  Anticoagulation has been stable  INR goal for atrial fibrillation 2.0-3.0 Why does it keep going? 14

4/7/13 Case 2  Type of atrial fibrillation: Recurrent, persistent  Treatment goals:  Rate control (goal 80-110)  Symptom goal  Rhythm goal Adding Antiarrhythmic Therapy  AAD for Rhythm Control  Amiodarone  SE makes less desirable for younger pts: monitor thyroid, liver and pulmonary  Dronedarone  Avoid with HF  Flecainide  Not with structural heart disease  Propafenone  Renal dosing; hospital start  Sotalol  Hospital start 15

4/7/13 Case 2  Normal structural heart  Flecainide 50 mg BID  Continue anticoagulation  Consider atrial fibrosis  Add spironolactone  Evaluate for sleep apnea Sleep Apnea  Sleep Heart Health Study  2800 patients  Took PSGs from the patients with afib and performed case control analysis  Matched sleep stages, no PVCs and no pauses  Used the entire group to estimate total event rates  62 total arrhythmic periods were found  Afib and NSVT were the most common Monahan, K, et al. JACC 2009 16

4/7/13 Mankopf,C, HRS 2010 Case 2 Next Visit  Return visit  Ongoing similar symptoms of fatigue and palpitations  ECG shows persistent atrial fibrillation  Options  Repeat cardioversion  Change AAD  Consider pulmonary vein ablation 17

4/7/13 Atrial Fibrillation Ablation  Atrial fibrillation ablation right now  CT scan of the chest beforehand  4 hours under general anesthesia  1 night in the hospital  Coumadin 1 month before and 3 months afterwards  80-85% cure rate  requires >1 procedure 10% of the time.  Complication rate 10% (mostly minor)  Bleeding/perforation 3% usually managed with a drain  Stroke 0.2%  Esophageal injury 0.1%  Death 0.1% 18

4/7/13 Case 3  88 year old female referred by PCP for atrial fibrillation found on ECG, HR 55 BPM  History  Mild dementia; diabetes, hypertension, recent fall and hip fracture  Symptoms  Fatigue, increased confusion, edema and shortness of breath Case 3 Diagnostic  Echocardiogram shows LV EF 25-30% with bi-atrial enlargement  Lab: renal insufficiency and anemia 19

4/7/13 Case 3 Treatment Goals  Rate control  Has underlying conduction issues if rate in the 50s not on any rate control meds  Rhythm control  Is this reasonable?  Could she be cardioverted?  Anticoagulation Assessing Bleeding Risk  HAS-BLED" 1 point for each  Hypertension  Abnormal Liver/Renal Function  Stroke History  Bleeding Predisposition  Labile INRs  "Elderly" (Age >e; 65) (fall risk)  Drugs/Alcohol Usage 20

4/7/13 Case 3 Treatment Plan  Rate control  PPM +/- AV node ablation  Rhythm management  Not appropriate  Anticoagulation  ASA 81 mg daily Vitamin D and Afib  30-50% of the Americans are Vitamin D deficient  Retrospective study of patients.  Vitamin D deficient patients slightly less likely to have atrial fibrillation (OR=0.83)  More likely to have HTN, DMII (OR=1.4, 2.31).  CAD/CM more likely (OR= 1.16, 1.4) Howard, PA et al, AJC, 109:359-363, 2012 21

4/7/13 Atrial Flutter Atrial Flutter  Regular arrhythmia  Flutter waves visible (CL 200-280ms)  V1- isoelectric component  III and aVF- downward continous  Difficult to rate control  Usually sustained until intervention (stable arrhythmia)  Pulmonary disease (DDimer)  Sleep apnea 22