265.1 ð é«åžçç
265.1.0.1 ð äžé éé»
265.1.0.1.1 Epidemiology
- ~ 38 million people globally with AF
- Lifetime risk ~ 25% (1 in 4 adults > 40 yr)
- 5Ã higher stroke risk vs normal sinus rhythm
- Mortality increased 1.5-2Ã
- Aging population drives incidence
265.1.0.1.2 Classification (2023 ACC/AHA)
265.1.0.1.2.1 Stages
- Stage 1 (At Risk): HTN + DM + obesity + OSA + smoking + family hx + ASCVD (modifiable risk factors)
- Stage 2 (Pre-AF): structural abnormalities + atrial flutter (without overt AF)
- Stage 3 (AF):
- 3A Paroxysmal: self-terminating < 7 days
- 3B Persistent: > 7 days; requires cardioversion to restore SR
- 3C Long-standing persistent: > 1 year continuous
- 3D Successful ablation: AF eliminated
- Stage 4 (Permanent): rhythm control abandoned
265.1.0.1.3 Pathophysiology
- Re-entrant + automatic focal triggers in atria
- Pulmonary veins = key triggering source (especially paroxysmal AF)
- Atrial fibrosis (substrate)
- Inflammation (PUFA, hsCRP)
- Aging
- HTN-induced atrial remodeling
- Sleep apnea + obesity + alcohol contribute
265.1.0.1.4 Causes / Risk Factors
265.1.0.1.4.1 Modifiable
- Hypertension (#1 modifiable)
- Obesity (BMI ⥠30 doubles risk)
- Diabetes mellitus
- Sleep apnea (OSA major contributor)
- Alcohol (binge + chronic)
- Smoking
- Physical inactivity OR excessive endurance exercise (paradoxical)
- Coronary artery disease
- Heart failure
- Valvular heart disease (mitral)
- Thyroid disease (hyperthyroidism)
265.1.0.1.5 Diagnosis
- ECG: irregularly irregular rhythm; no discrete P waves; fibrillatory baseline
- Ambulatory monitoring (Holter, event monitor, ILR) for paroxysmal
- Wearables (Apple Watch, KardiaMobile) â FDA-approved AF detection algorithms
265.1.0.1.6 Symptoms
- Often asymptomatic (40%+ â silent AF)
- Palpitations
- Dyspnea
- Fatigue
- Decreased exercise tolerance
- Chest discomfort
- Lightheadedness
- Syncope (especially elderly with rapid response or pre-excited AF)
- Stroke (presenting feature) â devastating
265.1.0.1.7 Management Pillars (4 Pillars 2024)
- Rate Control + Rhythm Control
- Anticoagulation for Stroke Prevention
- Risk Factor Modification
- Comorbid Disease Management
265.1.0.1.8 Stroke Risk Assessment
265.1.0.1.9 Bleed Risk Assessment
265.1.0.1.9.1 HAS-BLED Score
| Factor | Points |
|---|---|
| H Hypertension uncontrolled | 1 |
| A Abnormal renal/liver function | 1 each (max 2) |
| S Stroke | 1 |
| B Bleeding history / predisposition | 1 |
| L Labile INR (on warfarin) | 1 |
| E Elderly > 65 | 1 |
| D Drugs (antiplatelet, NSAID) or alcohol | 1 each (max 2) |
- Score ⥠3 = high bleeding risk
- Doesnât preclude anticoagulation; addresses modifiable factors
265.1.0.1.10 Anticoagulation Options (2023 ACC/AHA + 2024 ESC)
265.1.0.1.10.1 DOAC (Direct Oral Anticoagulant) â Preferred
- Apixaban (Eliquis): 5 mg PO bid (reduce to 2.5 mg if 2 of 3: age ⥠80, weight †60 kg, Cr ⥠1.5)
- Rivaroxaban (Xarelto): 20 mg PO daily (15 mg in CrCl 30-50)
- Edoxaban (Savaysa): 60 mg PO daily (30 mg in CrCl 15-50)
- Dabigatran (Pradaxa): 150 mg PO bid (110 if age > 80 or bleeding risk)
- Reversal agents: idarucizumab (dabigatran), andexanet alfa (apixaban + rivaroxaban + edoxaban)
265.1.0.1.10.2 Warfarin
- Reserved for:
- Mechanical heart valve (DOACs contraindicated â RE-ALIGN trial)
- Moderate-severe mitral stenosis
- Other specific scenarios (severe renal failure, antiphospholipid syndrome with high stroke risk, drug interactions)
- INR goal: 2.0-3.0
- Monitor INR
265.1.0.1.10.3 Left Atrial Appendage Occlusion (LAA Closure)
- Watchman (most common; FDA 2015)
- Amulet (Abbott; FDA 2021)
- For patients with contraindication to long-term anticoagulation (severe bleeding history, falls, mechanical issue)
- Reduces stroke risk equivalent to anticoagulation
- Procedure: catheter-based transseptal puncture; deploy device in LAA
- Short-term anticoagulation post (typically 6 weeks - 6 months) then aspirin
265.1.0.1.11 Rate vs Rhythm Control
265.1.0.1.11.1 Rate Control (Traditional Approach)
- β-blockers (metoprolol, bisoprolol, carvedilol) â first-line
- Non-dihydropyridine CCB (verapamil, diltiazem) â alternative or combination
- Digoxin (less commonly; especially in HFrEF)
- Goal: resting HR < 80 bpm; exercise HR < 110 bpm (lenient †110 at rest in some)
- Amiodarone in severe rate refractory
265.1.0.1.11.2 Rhythm Control (Increasingly Earlier)
- Cardioversion + antiarrhythmic drugs + catheter ablation
- CASTLE-AF: catheter ablation superior to medical therapy in HFrEF + AF
- CABANA: ablation vs medical equivalent (some subgroups ablation better)
- EAST-AFNET 4: early rhythm control improves outcomes in recently diagnosed AF
- Trend toward earlier rhythm control + ablation especially in younger + symptomatic + HF
265.1.0.1.12 Cardioversion
265.1.0.1.12.1 Electrical (Synchronized)
- Sedation + synchronized cardioversion
- 100-200 J biphasic
- Anticoagulation requirements:
- AF < 48 hr + low risk: cardioversion without anticoagulation OR DOAC pre-procedure
- AF > 48 hr or unknown duration:
- 3-4 weeks therapeutic anticoagulation pre-cardioversion + 4 weeks post
- OR TEE to exclude LAA thrombus + cardioversion + 4 weeks anticoagulation post
265.1.0.1.13 Antiarrhythmic Drugs (Maintenance)
- Amiodarone: most effective but toxic (thyroid, pulmonary, hepatic, ocular, dermatologic)
- Flecainide / Propafenone: no structural heart disease (Class IC)
- Sotalol: β-blocker + Class III; structural OK but QT monitoring
- Dofetilide: requires inpatient initiation
- Dronedarone: less effective than amiodarone but better safety profile (no thyroid/pulm toxicity)
265.1.0.1.14 Catheter Ablation
265.1.0.1.14.1 Indications
- Symptomatic paroxysmal AF (1st-line increasingly)
- Persistent AF
- Failed antiarrhythmic drug
- HFrEF + AF (CASTLE-HF)
- Recently diagnosed AF (EAST-AFNET 4)
265.1.0.1.16 Special Situations
265.1.0.1.16.1 AF + HF
- Diuretics + ACEi/ARB/ARNI/SGLT2i for HF
- Rate control with β-blocker (not amiodarone first-line)
- Rhythm control improving outcomes (CASTLE-HF â ablation)