A-Fib Treatment

T/F: the incidence of A-fib decreases as we age

false you silly lady

what can a-fib be caused by?

Ischemic heart disease, cardiomyopathy, fibrotic disease, electrolyte abnormalities, drugs, genetic diseases

which conditions cause scarring or fibrotic tissue in the heart?

ischemic heart disease, cardiomyopathy, and fibrotic diseases

what can cause changes to the cardiac action potential?

electrolyte abnormalities

what is a-fib?

a progressive disease that occurs when atrial tissue is modified due to abnormalities in structure or function and requires different strategies at different stages.

what does an ECG look like for a-fib

disorganized and irregular atrial activity; has no distinguishable atrial depolarization/contraction (p-waves); makes the atria look like they are quivering instead of contracting

rates for the atria in a-fib

600-800 bpm

rates for the ventricles in a-fib

usually 100-180 bpm

how is a-fib triggered

rapidly firing ectopic beats in the atria - most commonly where pulmonary veins connect to the atria

risk factors for a-fib?

concomitant cardiac disease, diabetes mellitus, obesity, obstructive sleep apnea, hyperthyroidism, smoking, and many more

Types of a-fib

paroxysmal, persistent, longstanding persistent, permanent

what is paroxysmal afib

terminates within 7 days on onset

what is persistent afib

lasts > 7 days

what is longstanding, persistent afib

lasts > 12 months

what is permanent afib?

the patient and clinician have decided that there will be no more effect to restore or maintain sinus rhythm :(

afib clinical manifestations

fatigue, palpitations, SOB, hypotension, dizziness, lightheadedness, syncope

T/F: many patients with afib experience symptoms

False!!

what do you have an increased risk of getting/having due to afib?

stroke, heart failure, dementia, hospitalization, and mortality (and poor costs lots to treat 😐)

what is afib with rapid ventricular rate (RVR)

a generally acute presentation with higher HRs from more conduction through the AV node; often needs immediate intervention as it may lead to syncope/loss of consciousness

afib prevention overview:

foundation of optimal management is to treat risk factors and implement lifestyle changes to decrease the likelihood of developing Afib

Once afib develops what are the 3 important care processes that must be addressed?

stroke risk assessment and treatment, optimizing all modifiable risk factors, and symptom management using rate and rhythm control strategies

T/F: patients can move between substages of a-fib

true <3

what does HEAD-2-TOES stand for?

risk factors and behavioral changes for afib: Heart failure, Exercise, Arterial hypertension, Diabetes, Tobacco, Obesity, Ethanol, Sleep

what scoring tool is used to determine who should be anticoagulated to prevent stroke?

CHA₂DS₂VASc Score

T/F: strokes are less detrimental to the quality of life in patients with afib than those without it

FALSE!!!!!!!!!

where can blood clots form in the heart ?

clot can form in the left atrial appendage

categories of patient absolute risk of stroke?

low, intermediate, and high

what is a low risk of stoke?

< 1 % annualized risk of stroke

what is intermediate risk of stroke

1-2% annualized risk of stroke

what is high risk of stroke

> 2% annualized risk of stroke

what does the C in CHA₂DS₂VASc Score stand for?

congestive heart failure

what does the H in CHA₂DS₂VASc Score stand for?

Hypertension

what does the A₂ in CHA₂DS₂VASc Score stand for?

age > 75

what does the D in CHA₂DS₂VASc Score stand for?

diabetes mellitus

what does the S₂ in CHA₂DS₂VASc Score stand for?

Stroke/TIA/Systemic Embolism

what does the V in CHA₂DS₂VASc Score stand for?

Vascular disease

what does the A in CHA₂DS₂VASc Score stand for?

Age 65-74

what does the Sc in CHA₂DS₂VASc Score stand for?

Sex Category (female)

points for congestive heart failure in CHA₂DS₂VASc Score

1

points for hypertension in CHA₂DS₂VASc Score

1

points for age > 75 in CHA₂DS₂VASc Score

2

points for diabetes mellitus in CHA₂DS₂VASc Score

1

points for stroke/TIA/Systemic embolism in CHA₂DS₂VASc Score

2

points for vascular disease in CHA₂DS₂VASc Score

1

points for age 65-74 in CHA₂DS₂VASc Score

1

points for being female in CHA₂DS₂VASc Score

1

how many points do males need on the CHA₂DS₂VASc Score for anticoagulation

>= 2

how many points do females need on the CHA₂DS₂VASc Score for anticoagulation

>= 3

define congestive hf

signs/symptoms of left or right ventricular failure or objective evidence of cardiac dysfunction (ex: on ECHO)

define hypertension <3

a resting BP of > 140 systolic and/or > 90 mmHg diastolic on at least 2 occasions OR active treatment with antihypertensives

define diabetes mellitus

fasting plasma glucose >= 126 mg/dL or treatment if antidiabetic medication

define stroke/TIA/systemic embolism

ischemic stroke, transient ischemic attack, peripheral embolism, pulmonary embolism

define vascular disease

CAD or PAD

decisions about anticoagulation must balance the risk of __________ with the risk of _______________ on anticoagulation

stroke; bleeding

what are some interventions we can suggest to reduce bleed risk on anticoagulants?

discontinuing antiplatelets if/when appropriate, discontinuing NSAIDs

what med is the HAS-BLED score validated for?

warfarin - not DOACs

what can the HAS-BLED score be used in?

A risk-benefit discussion to determine safety of anticoagulation

what is are risk-factors listed in HAS-BLED

hypertension, abnormal liver or kidney function, stroke history, bleeding history, labile INR, elderly (> 65), drug or alcohol abuse

chronic anticoagulation oral agents

warfarin, dabigatran, rivaroxaban, apixaban, edoxaban

acute anticoagulation parenteral agents

heparin, LMWH, direct thrombin inhibitors, fondaparinux

in patients with a-fib and without a history of moderate to severe rheumatic mitral stenosis or mechanical heart valve who are also candidates for anticoagulants, what can be given to them?

DOACs (if can’t have DOAC give them warfarin)

patients with afib and moderate-severe mitral stenosis or mechanical heart valves, what can be given to them for anticoagulation

warfarin

patients with afib and a moderate-high risk of stroke and a CI to long-term anticoagulation due to a non-reversible cause, what is a reasonable treatment option?

A percutaneous left atrial appendage occlusion (LAAO)

in patients with a moderate-high risk of bleeding on oral anticoagulation, what may be a reasonable treatment for them?

A LAAO based on patient preference, which careful consideration of procedural risk with the understanding that data for oral anticoagulation is more extensive

how to optimize heart failure due to being a risk factor for afib?

follow those HF guidelines as appropriate (good luck queen)

how to optimize exercise for afib

moderate-to-vigorous exercise training to a target of 210 minutes per week is recommended

why is exercise beneficial for afib?

reduced afib symptoms and burden, increase maintenance of sinus rhythm, increase functional capacity and improve quality of life

how to optimize arterial hypertension

optimal BP control is recommended to reduced afib recurrence and afib related CV events

how to optimize diabetes

follow guidelines as appropriate…

how to optimize tobacco use in patients

strongly advise them to quit smoking and receive GDMT for tobacco cessation to help mitigate the increased risks of afib related CV complications and other adverse outcomes

how to optimize the fatties (BMI >= 27 kg/m2)

weight loss is recommended with an ideal target of at least 10% weight loss to reduce afib symptoms, burden, recurrence, and progression to persistent afib

how to optimize ethanol usage in patients

patients seeking a rhythm control strategy should minimize or eliminate alcohol consumption to reduce afib recurrence and burden

T/F: the role of treatment of sleep-disordered breathing to maintain sinus rhythm is uncertain but screening for obstructive sleep apnea is reasonable in afib patients

true

how can symptoms of afib be managed?

with either rate or rhythm control

what is rate control?

allowing patients to remain in atrial fibrillation but control the heart rate to control symptoms

what is the heart rate target

should be guided by underlying symptoms but in general aiming at a resting rate of < 100-110 bpm

what is rhythm control

the goal of maintaining sinus rhythm

how can rhythm control be achieved?

via medications, ablation, or a combination.

what is cardioversion

the change from afib to sinus rhythm

what are the two methods to maintain sinus rhythm?

chemical (utilizing antiarrhythmic drugs) and ablation (utilizing a procedure to block conduction in the tissue causing the arrythmia

patient factors/variables that favor rate control for afib

patient preference, “older,” longer history of afib, fewer symptoms

patient factors/variables that favor rhythm control for afib

patient preference, “younger,” shorter history of afib, more symptoms

physical examination anatomy that favors rate control for afib

easily controlled heart rate, larger LA, less LV dysfunction, and less AV regurgitation

physical examination anatomy that favors rhythm control for afib

difficult to control HR, small LA, more LV dysfunction, and more AV regurgitation

drugs used for rate control

beta-blockers, non-DHP CCBs, digoxin, and amiodarone

Adverse events for beta-blockers in afib

AV block, bradycardia, hypotension

adverse events for non-DHP CCBs in afib

AV block, hypotension, bradycardia

adverse events for digoxin in afib

anorexia, N/V, ventricular arrhythmias

adverse events for amiodarone in afib

AV block, bradycardia, and hypotension

DDI for non-DHP CCBs

CYP3A4 inhibitors

DDI for digoxin

P-gp substrate (concentrations increased by amiodarone, dronedarone, and verapamil)

DDI for amiodarone

inhibits CYP1A2, CYP2C9, CYP2D6, and CYP3A4 which can increase concentrations of warfarin and select statins

which drugs are recommended for long-term rate control with the choice of agent according to underlying substrate and comorbid conditions?

beta-blockers and non-DHP CCBs (diltiazem, verapamil)

which drugs should not be administered to patients with afib and and EF < 40%?

non-DHP CCBs

which drug is a reasonable long-term rate control option when used in combo with other rate-controlling agents or as monotherapy if other agents are not tolerated or CI for patients with afib and HF symptoms

digoxin <3

what is the target serum concentration of digoxin?

goal < 1.2 ng/mL

long term rate control first-line agent in patients with EF <= 40%

beta-blockers

if patients with EF <= 40% need more rate control what can be added or used as monotherapy as a second line agent?

digoxin

long term rate control first-line agent in patients with EF > 40%

beta-blockers or non-DHP CCBs

if patients with EF > 40% need more rate control what can be added on or used as monotherapy as a second line agent?

queen digoxin