• AHA 2019 Focused Update

• paroxysmal = self-terminate within 7 days
• persistent = beyond 7 days
• long-standing persistent = 1 year
• permanent = unsuccessful reversion

• Overview
• Incidence
• Prevalence
  • 8% NCS
  • 30% NCS thoracic
  • 45% cardiac
• Gender
  • female > male

• ⬆risk MACE
  • HR > 110
  • HF

• idiopathic

• Cardiac = structural / VHD

  • IHD, MV disease, PE, cardiomyopathy

• Systemic disease

  • Endo = hyperthyroidism
  • Electrolyte derangement
  • Sepsis
  • Alcohol

• Trauma = thoracic surgery

  • high risk surgery = pneumonectomy, CABG, CABG + valve surgery

• CHADS2

  • estimate of stroke risk
  • CCF, HTN, Age 75, DM, Stroke (2 points)

• CHA2DS2-VASc

  • recommended in 2014 AHA guidelines
  • CCF, HTN, Age 75 (2 points), DM, Stroke (2 points)
  • Vascular disease (PVD, MI, Aortic plaque)
  • Age 65-74
  • Sex Category (female = higher risk = 1 point)

• AHA 2019 Recommendations

  • score 0 = low risk
  • score 1 = moderate risk, consider ACT
  • score 2+ (males) / 3+ (females) = high risk, for ACT
  • CHA2DS2-VASc has 3 more variables so will identify more patients at high risk
  • Caveat = score 1 from gender (female, under 65, no other RF) = no ACT
  • NOAC unless mitral stenosis (mod/sev) or mechanical heart valve
  • dabigatran should not be used in mechanical heart valve (harm)

• HAS-BLED

  • estimate of risk of bleeding on ACT
  • 0-2 = lower risk
  • HTN, Abnormal renal function, Abnormal liver function, Stroke,
  • Bleeding history, Labile INR, Elderly age 65, Drugs or alcohol excess

• ATRIA = Bleeding risk score

  • Anaemia
  • Severe renal disease = GFR < 30 mL/min
  • Age > 75
  • Prior haemorrhage, eg GI, ICH
  • HTN

• pulmonary veins contain same cells as in LA
  • they can initiate / transmit a depolarisation
• AVN is gatekeeper for conduction to ventricle
• lack of coordinated atrial contraction
  • 1:loss of atrial kick = phase 4 / A wave
    • more in MS / HCM / LVH
  • 2:risk of clot
    • atrial clot + ATE
• • uncoordinated atrial contraction
• HR / ventricular rate dependent on AVN conduction

• ⬆LOS
• ⬆MM

• irregularly irregular pulse

• ECG
  • absent p waves

• most will be paroxysmal, and self-revert in 24-48 hours

• RATE control

  • aim = slow AVN conduction and ventricular rate
  • digoxin
  • BB
    • caution in LVF
  • CCB = verapamil, diltiazem
    • may cause more ⬇BP
  • amiodarone
  • opioids

• RHYTHM control

  • cardioversion
    • requires ACT > 3 weeks with INR 2-3
    • TOE evidence of no LA thrombus
    • haemodynamic compromise
    • begin at 100 J
    • synchronise with QRS
  • pulmonary vein isolation
  • AVN ablation
    • esp when medications are ineffective / not tolerated
  • overdrive pacing

• anticoagulation

  • CHA2DS2-VASc
    • ACT not required = males 0 / females 1
    • ACT = males 2 / females 3
  • NOACs recommended over warfarin in AF with MS / mechanical heart valve
  • bridge for CHADS2 4+

• RVR

  • flecainide
  • success 67-92% within 1-6 hours, usually 0.5 hr

• Pre-op
  • main issue is management of periop ATT
  • bridging therapy for warfarin is not always needed, consult LHD
  • balance bleeding vs ischaemic stroke
  • CHADS2 score
  • Bridge Study 2015
    • no bridging ACT was non-inferior to periop bridging with LWMH
    • low numbers of high CHADS2 score patients
    • most surgeries were not high risk
  • approach
    • institutional practice
    • individual balance of risk and benefit assessment
• Intra-op
  • if unstable, DCCV
  • short-acting BB = esmolol
  • remifentanil = 0.5 mcg/kg = 40 mcg
  • amiodarone is too slow
  • ⬇BP ⮕ vasopressor
    • ensure adequate coronary BQ (ischaemia can cause / exacerbate AF)
• Post-op

Bridging and Interruption (AHA 2019)

• AF + Mechanical heart valve
  • Bridging therapy with UFH / LMWH
  • Decisions on bridging therapy should balance the risks of stroke and bleeding
• AF only
  • Decisions should balance risks
• Idarucizumab
  • recommended for life-threatening bleeding or urgent procedure
• Andexanet alfa
  • Can be useful for the reversal of rixaroxaban and apixaban in life-threatening / uncontrolled bleeding

Rapid AF (AHA 2019)

• ACS + AF with RVR
  • DCCV if HDI / ongoing ischaemia / inadequate rate control
  • IV BB if no HF / HDI / bronchospasm
  • Amiodarone / digoxin = if severe LVF / HDI
  • Verapamil (non-DHP) = if stable = no HF or HDI

Final FRCA In A Box

2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons

https://clincalc.com/Cardiology/Stroke/CHADSVASC.aspx