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atrial fibrillation (AF)

Classification: 1) paroxysmal atrial fibrillation - intermittent, stops spontaneously within 7 days of onset 2) persistent atrial fibrillation - persists for >= 7 days 3) long-standing persistent last >= 1 year 4) permanent refers to cases where any attempts to maintain sinus rhythm have been abandoned [5] Etiology: 1) hypertension, systolic hypertension [97] - lowering systolic BP lowers risk of new-onset AF 2) acute alcohol ingestion (holiday heart syndrome) 3) ischemic heart disease 4) myocardial infarction 5) congestive heart failure 6) valvular heart disease - mitral valve disease - mitral stenosis: rheumatic heart disease (diastolic murmur at apex) - mitral regurgitation (holosystolic murmur) 7) pericarditis 8) sick sinus syndrome [6] 9) pulmonary disease a) pulmonary embolus b) pneumonia c) chronic obstructive pulmonary disease (COPD) 10) s/p open heart surgery 11) theophylline intoxication 12) endocrinopathies a) hypothyroidism b) hyperthyroidism - even subclinical hyperthyroidism increases risk of atrial fibrillation [51] c) pheochromocytoma 13) infections 14) cardiac tumors: atrial myxoma [6] 15) substrate for acute atrial fibrillation [183] - atrial scars from prior cardiac surgery - lung disease - chronic pressure overload 16) triggers of acute atrial fibrillation [183] - sepsis, volume changes, pericardial inflammation, thyrotoxicosis, medications 17) risk factors - [23] a) obesity - obesity appears to be associated with electrical & structural changes in the heart that increase the risk of AF [95] - weight reduction appears to lower that risk [95] b) diabetes mellitus [47] (weak association) c) high pulse pressure d) advanced age e) long-term endurance exercise (2-10 fold risk) [30] due to left atrial enlargement f) long-term glucocorticoids, as little as 7.5 mg of prednisone/day [33] g) chronic renal failure (HR=3.2 GFR <30 ml/min/1.73 m2) - albuminuria [39] h) premature atrial contractions (RR=1.2] [63] i) elevated resting heart rate (RR=1.1) [199] j) pharmaceutical & other drugs - NSAID & COX2 inhibitors - HR=1.2-1.3; HR=1.5-1.7 for new users [40] - HR=1.7 for use in elderly [70] - alcoholic beverage use, even in moderation increases risk [80] - smoking - cocaine, methamphetamine, opioids, cannabis [176] - marine omega-3 fatty acids supplementation > 1 gram/day [189] k) asthma (RR=1.4, RR=1.7 for uncontrolled asthma) [141] l) bereavement from death of a partner (RR=1.9) [106] m) neurogenic mechanism suggested for atrial fibrillation after ischemic stroke [138] n) sleep apnea [5] o) elevated plasma Lp(a) evidence conflicting [173] Epidemiology: 1) most common sustained arrhythmia 2) prevalence is 96.2/1000 person-years in men & 49.4/1000 person-years in women [94] - prevalence is 6.4% at 65-69 years & 28.5% at >= 85 years of age [179] 3) 50% of patients with AF are >= 75 years of age [68] - AF affects 10-19% of Americans over age 75 [55] 4) incidence is 14.2 per 1000 person-years at 65-69 years & 50.8 per 1000 person-years at >= 85 years [179] - incidence is greater in men 33.4 per 1000 person-years vs women 16.8 per 1000 person-years [179] 5) > 98% of patients have comorbidity 6) 14% increase in hospitalizations for atrial fibrillation 2000-2010 [75] 7) lifetime risk 23% among persons with optimal risk factors [140] 8) recurrent atrial fibrillation occurs in 32% of patients with transient new-onset atrial fibrillation during hospitalization [185] Pathology: 1) multiple simultaneous wandering wave fronts of activation with simultaneously occurring reentrant circuits within the atria 2) any disease process that increases atrial size (left atrial enlargement) &/or decreases atrial conduction or refractory period may result in AF 3) the pulmonary veins have been implicated in generating the electrical current of AF [19] 3) atrial fibrillation may induce atrial cardiomyopathy [6] 4) resultant atrial cardiomyopathy promotes further atrial fibrillation 5) subtle abnormalities in left ventricular function, not corrected by ablation with cardioversion described [123] 6) calcitonin is produced by atrial myocytes & diminishes production of collagen by atrial fibroblasts. [161 - in mice, increasing atrial calcitonin production prevents fibrosis & atrial fibrillation - inhibiting calcitonin production enhances fibrosis & atrial fibrillation Genetics: - familial atrial fibrillation associated with defect in: LMNA, KCNQ1, KCNE2, NPPA Clinical manifestations: 1) may be asymptomatic 2) palpitations 3) irregular heart rate, irregularly irregular pulse 3) dizziness 4) dyspnea 5) angina 6) syncope 7) heart failure 8) systemic embolism 9) no A wave in jugular venous pulse 10) pulse deficit (auscultated pulse > palpated pulse, especially radial artery) 11) variable S1 heart sound Laboratory: 1) thyroid function tests 2) theophylline level if indicated 3) urinary metanephrines if indicated 4) pulse oximetry 5) digoxin level if possible exposure 6) high levels of plasma GDF15 (median 1383 ng/L) associated with increased risk for major bleeding, mortality, & stroke (investigational) [88] Special laboratory: 1) electrocardiogram a) irregularly fluctuating baseline: atrial rate 350-600 bpm b) no P waves - deformed T waves or ST segment may hide P waves c) irregular spacing of R waves d) a regular ventricular rate (regular spacing of R waves) suggests complete AV block with a junctional rhythm [5] e) wide complex tachycardia may occur with pre-excitation (WPW); look for delta wave [5] 2) echocardiogram a) rule out valvular heart disease, i.e. mitral stenosis b) assess left atrial size: an enlarged left atrium is unlikely to maintain sinus rhythm if cardiovertedy 3) sleep study for evaluation of sleep apnea [5] 4) also see paroxysmal atrial fibrillation 5) complex & costly screening protocols not required for detection [159] Staging: - stage 1: risk factors for atrial fibrillation - stage 2: pre-atrial fibrillation because of structural or electrical findings - stage 3: paraoxysmal atrial fibrillation - stage 4: permanent atrial fibrillation [190] Differential diagnosis: - multifocal atrial tachycardia in COPD - digitalis toxicity - atrial tachycardia with AV block - preexitation tachycardia - ventricular tachycardia - AF may appear as wide-complex tachycardia if intraventricular conduction delay (RBBB) Complications: 1) rapid ventricular response - if unstable, immediate synchronized cardioversion [188] 2) potentially serious complications with a) Wolf-Parkinson-White syndrome b) aortic stenosis or mitral stenosis -> need for atrial kick to maintain cardiac output c) diastolic dysfunction 1] non compliant ventricle, impaired ventricular filling 2] cardiovascular collapse with rapid ventricular response 3) thromboembolism (see risk factors for thromboembolism) a) the majority of thromboembolic strokes occur in association with AF b) stroke risk is 4%/year for untreated patients - estimated 1-year stroke risk for untreated patients 66 years of age is 0.7% increasing to 1.7% at 74 years [169] c) embolic stroke risk for patients on aspirin alone 1] 2%/year for low risk patients 2] 4%/year with any risk factor 3] as high as 18%/year for high risk patients d) patients with resolved AF still at risk for stroke or TIA - 12.1 vs 7.4 per 1000 person-years (no AF) not as high as those with current AF (16.7 per 1000 person-years) [139] e) 2-fold risk of silent stroke [82] - study unable to assess possible risk reduction with anticoagulation [82] f) 84% of patients with atrial fibrillation & ischemic/ embolic stroke with no or inadequate anticoagulation [125] g) > 90% of atrial thrombi in patients with non-valvular atrial fibrillation are believed to originate in the left atrial appendage g) risk greater for women than men (independent of warfarin) - see CHADS2 score [105] - risk not greater for lone atrial fibrillation [45] h) chronic renal failure increases risk of thromboembolism [124] i) thromocytopenia increases risk of thromboembolism [191] 4) perioperative atrial fibrillation associated with increased risk of atrial fibrillation after surgery - RR = 1.3 for cardiac surgery - RR = 2.0 for non-cardiac surgery [81] 5) hemorrhage associated with anticoagulation - has-bled score estimates risk - risk factors include [53] - hypertension - renal insufficiency [124] - abnormal liver function - prior stroke - history of bleeding or predisposition to bleeding - labile INR - age > 65 - concurrent aspirin or NSAID - alcohol intake in excess of recommended limits - thromocytopenia associated with increased risk of bleeding & thromboembolism [191] - restart of oral anticoagulation after GI bleeding is associated with reduced risk of thromboembolism & lower mortality [103] - 1 year risk of colorectal cancer after lower GI bleed in patients anticoagulated for atrial fibrillation is similar to that for patients without atrial fibrillation or anticoagulation [155] (3.7% < 65 years, 8.1% > 75 years) 6) cognitive impairment & vascular dementia linked to atrial fibrillation [58] a) high prevalence of mild cognitive impairment in hospitalized elderly with chronic atrial fibrillation [52] b) association attenuated but not eliminated by excluding patients with heart failure [58] c) anticoagulation diminishes risk of dementia [132] d) rhythm control, especially catheter ablation may be best strategy to diminish risk of dementia [178] 7) increases risk of myocardial infarction (RR = 2) [61] - increased risk for sudden cardiac death (0.6/1000) [119] 8) increased risk for heart failure (11.1/1000) [119] 9) increased risk for renal failure (6.6/1000) [119] 10) increased cardiovascular mortality (2.6/1000) [119] 11) newly diagnosed atrial fibrillation in women is associated with increased cancer risk (1.4% vs 0.8/year) & vice versa [108] 12) increased mortality (3.6/1000) [119] - mortality risk associated with newly diagnosed atrial fibrillation has not changed for 1972-2015 [160] 13) little correlation between estimated & patient perceived risk for stroke or hemorrhage - 1 in 5 patients believe anticoagulation lowers stroke risk by 90% (trials suggest risk reudction about 2/3) [149] - almost all older adults > 64 years under-estimate bleeding risk [170] 14) increased risk of syncope & falls in the elderly [156] Management: - hospitalize for - hemodynamically unstable, prepare for cardioversion (see below) [5,12] - high risk for thromboembolism - immediate anticoagulation with heparin & warfarin [5] - may be difficult to distinguish cardiogenic tachycardia (suppress) from tachycardia due to physiological needs (allow) - assess intravascular volume & other noncardiac determinants of a rapid ventricular response prior to treatment [89] - correct precipitating causes (first line) - correct hyperthyroidism prior to cardioversion [7] - correct hypovolemia [89] - weight loss & intensification of exercise, especially when BMI > 27 - AHA/ACC class 1 recommendation for newly diagnosed atrial fibrillation in addition to consideration of anticoagulation (see below) [147,158,188] - rate control formerly preferred strategy (exception WPW) (see below) === cardioversion === - DC cardioversion (50, 100, 200, 300, 360 joules) - more effective than chemical cardioversion [44] - chemical cardioversion - pharmacologic agents - class 1A, 1C or 3 antiarrhythmic agents - amiodarone & dronedarone formerly class 3 antiarrhythmics now antiarrhythmic multichannel blockers - useful for cardioversion & maintenance of sinus rhythm - adenosine is not effective [5] - conversion & maintenance of sinus rhythm - indications - urgent cardioversion if patient is unstable [5] - hypotension - unstable angina, myocardial ischemia - acute heart failure - mitral stenosis - mitral regurgitation - new onset of atrial fibrillation within 48 hours - immediate cardioversion in the emergency department no better than cardioversion at 48 hours [148] - early rhythm control (median time from diagnosis = 36 days) may be associated with better outcomes than rate control [158] - patients with continued symptoms despite adequate rate control [5] - contraindications: - atrial thrombus: delay cardioversion until completion of 4-6 weeks of anticoagulation with warfarin - if patient is unstable, do not delay cardioversion for atrial thrombus, to check INR or any other reason - anticoagulation - IV heparin prior to emergent cardioversion if duration of AF not known [5] - 3 weeks prior to elective cardioversion - if atrial fibrillation < 48 hours, then may proceed with cardioversion without prior anticoagulation [6] - trans-esophageal echocardiography (TEE) may be use to determine presence of atrial thrombosis; if none then may proceed with cardioversion without prior anticoagulation [6] - edoxaban is as safe & effective as enoxaparin-warfarin [118] - major bleeding less with dabigatran than warfarin (1.6% vs 6.9%) without difference in thrombosis [127] - continue for 4 weeks after successful cardioversion [5] === maintenance of sinus rhythm === - antiarrhythmic therapy for maintenance of sinus rhythm - rhythm-control strategies, especially ablation, are effective in protecting cognitive function, reducing dementia risk & improving quality of life [193] - younger, symptomatic patients benefit more often than elderly - class III agents - amiodarone (most commonly used, formerly class 3 agent) - 400 mg for 30 days, then 200 mg QD - especially useful with structural heart disease - 1st line agent for AF if ischemic heart disease & LV dysfunction [5] - symptomatic benefit only [196] - sotalol in patients with CAD - dronedarone (Multaq) [31] - class 1C agents, if no structural heart disease - flecainide 100 mg BID, or - propafenone 150-225 mg TID - 30-50% of patients will maintain sinus rhythm after 1-2 years - PRN flecainide or sotalol for paroxysmal atrial fibrillation - ranolazine (Ranexa) - may be useful for maintenance of sinus rhythm - may accelerate chemical cardioconversion with amiodarone - observational study finds mortality benetit for rhythm control vs rate control at 5 years (RR = 0.89) & 8 years (RR = 0.77), but not at 6 months (RR = 1.07) [46] - lower risk for adverse outcomes with a rhythm-control strategy, but only when initiated within one year of diagnosis [5,168] - rhythm control associated with lower adverse cardiovascular risk than rate control in newly diagnosed patients with atrial fibrillation [175] - use of antiarrhythmic agents in patients with new onset atrial fibrillation increases risk of syncope (RR=2.0) & pacemaker placement (RR=5.0) [195] === ablation === - ablation first line strategy for all LV ejection fractions [190] - AV node ablation with permanent ventricular pacing - refractory ventricular rate [27] - radiofrequency ablation of focal atrial fibrillation in younger patients [35] - catheter ablation for persistent or paroxysmal atrial fibrillation - reduces dementia & mortality vs rate control with anticoagulation in older patients (>= 65 years) with or without - left ventricular systolic dysfunction - left ventricular diastolic dysfunction - hypertension - diabetes mellitus - ischemic stroke - chronic kidney disease [187] - reduces hospitalization for worsening heart failure in patients with HFrEF [135] - radiofrequency ablation vs cryoablation [120] - pulmonary vein isolation/ablation may become 1st line therapy [18,20,21,22,27] - indicated if rhythm control needed & not achievable with antiarrhythmics (i.e. WPW) [69] - more extensive ablation than pulmonary vein isolation alone does not result in better outcomes for patients with persistent atrial fibirllation [93] - repeat ablations common 20-30% [93] - residual cardiac arrhythmias in 1/2 of patients [65] - risk of cardiac tamponade [65] - maze procedure may be useful for patients undergoing cardiac surgery for other reasons [5] - anticoagulation should continue for 2-3 months after ablation [5] - continue warfarin past 2-3 months even in the absence of evidence of further atrial fibrillation if CHADs2 score >= 2 [5,98] - left atrial appendage closure - noninferiority for preventing stroke (with lower bleeding risk) compared with warfarin - procedure-related adverse events (pericardial effusion, major bleeding, device embolization) in ~ 1 in 25 device-implanted patients [146] - anticoagulation after successful catheter ablation reduces risk of thromboembolism only in highest risk patients [192] === rate control strategy === - control ventricular rate via AV nodal blocking agents formerly preferred strategy (excluding WPW)# [11,13] - Ca+2-channel antagonists (NOT dihydropyridines) - diltiazem reduces frequency & severity of symptoms - diltiazem 360 mg/day PO appears to be the best choice [54] - IV for rapid ventricular response [125] - verapamil reduces frequency of symptoms [54] - beta-blocker - metoprolol, atenolol, carvedilol - may not reduce either the frequency or severity of symptoms [54] - may exacerbate symptoms of asthma or obstructive lung disease [125] - digoxin (last resort, no other options) [91] - not very effective in controlling ventricular response during exercise - add calcium channel antagonist or beta-blocker in patients controlled at rest, but with tachycardia during exercise - do not use as single agent for rate control [5] - may be associated with higher mortality among patients with atrial fibrillation (RR= 1.2) [79,91,137] - higher risk of toxicity in patients with renal failure [125] - no difference in patient-reported quality of life vs beta blocker [162] - lenient rate control (< 110/min) with outcomes similar to standard control (< 80/min) [36] - diltiazem may be best choice (metabolized by liver) - symptomatic benefit only [196] - rate + rhythm control offers better symptom management than rate control alone [5] === anticoagulation for rate control strategy === - anticoagulants reduce risk of ischemic stroke - indications for anticoagulation [16,76] - CHADS2 score >= 2 (men), >= 3 (women) [147] (see CHADS score) - anticoagulation may be reasonable in men with CHADs score of 1 or women with CHADS score of 2 [147] - benefit of anticoagulation unlikely with CHADS2 score of 1 [92] - combination of anticoagulant & antiplatelet agent rarely indicated (see antiplatelet therapy below & Complications: above) - in patients with history of intracranial hemorrhage, threshold for CHADS2 score >= 6 [109] - transient ischemic attack - warfarin if hypertrophic cardiomyopathy regardless of CHADs score [2] - only 1/3 of patients receive recommended anticoagulation [110] - almost 40% of eligible patients do not receive oral anticoagulants [131] - anticoagulation in patients with ESRD on dialysis - apixaban 5 mg BID is associated with a reduced risk of thromboembolism & mortality risk (GRS11 cites a 2018 paper) [68,172] later questioned in a more recent 2020 paper [151] (cited below) - anticoagulation is not associated with lower embolic risk in patients with ESRD on dialysis, but is associated with higher bleeding risk [151] - anticoagulation in elderly > 75 years reduces 1.5 risk of dementia 12% [181] - risks of anticoagulation for atrial fibrillation in demented frail elderly may exceed benefits [180] - direct oral anticoagulants (thrombin inhibitor, factor Xa inhibitor, DOAC) - preferred vs warfarin [147,166] - MKSAP19 notes warfarin only FDA-approved agent for valvular AF [5] - switching from warfatin to DOAC in frail elderly may result in increased risk of bleeding without benefit in thromboprophylaxis [186] - more effective & safer than warfarin [64,120,166] - reduced all-cause mortality relative to warfarin [133] - better & safer than warfarin for stroke prevention in patients with bioprosthetic valvular atrial fibrillation [166, 184] - safer than warfarin in the very old [164] - strongly recommended if therapeutic INR not achieved with warfarin [69] - not for use in patients with mechanical heart valves or moderate to severe mitral stenosis [5,69,147] - apixaban seems to be direct oral anticoagulant of choice [133] - apixaban more effective & safer than rivaroxaban [152] - continue 81 mg aspirin with DOAC if MI in past year - risk using pooled cohort equations not a consideration for dual therapy - thrombin inhibitor (dabigatran) [8] - FDA approved (2010) & included in AHA guidelines for treatment of atrial fibrillation [38] - no need for therapeutic monitoring (INR) - superior to warfarin in Asians [121] - lower risk of hospitalization for GI bleed & for intracranial hemorrhage than with rivaroxaban [121,122] - less risk of osteoporotic fracture than with warfarin (0.7 vs 1.1 per 100 person-years) [129] - higher risk of extracranial bleeding in patients > 75 years of age [68] - check renal function [66] - renal dosing not examined in clinical trials [68] - renal dosing 110 mg BID associated with lower risk for hemorrhagic stroke than 70% warfarin dosing (RR=0.46) [126] - factor Xa inhibitor - rivaroxaban - not inferior to wafarin in preventing embolic stroke [42] - superior to warfarin in Asians [121];reduced risks for ischemic stroke & systemic embolism,intracranial hemorrhage, & all-cause mortality at 1 year [121] - higher risk of hospitalization for GI bleed & for intracranial hemorrhage than with dabigatran [121,122] - apixaban - better than warfarin, regardless of number of concurrent medications [48,112] - apixaban with lowest risk of GI bleed among DOACs [177] - rates of ischemic stroke, systemic embolism, intracranial hemorrhage & all-cause mortality similar for apixaban, dabigatran, edoxaban, & rivaroxaban including for patients >= 80 years & those with chronic kidney disease [177] - in patients with ESRD, apixaban associated with lower risk of major bleeding than warfarin, & with reductions in thromboembolism & mortality (dose 5 mg BID) [142] - not associated with benefit in patients with ESRD on dialysis [151] - alternative to warfarin in patients with end-stage renal disease [147] - safe with close monitoring in patients with ESRD on dialysis (MKSAP19) [5] - among Medicare recipients with atrial fibrillation >= 65 years, apixaban is associated with lower risk of major ischemic events & major hemorrhage than rivaroxaban [171] - seems to be direct oral anticoagulant of choice [133] - low-dose edoxaban 15 mg/day effective in reducing thromboembolism & stroke in elderly >80 years of age [157] - check renal function [66] - renal dosing of factor Xa inhibitor associated with increased mortality relative to 70% warfarin dosing (RR=0.1.48 for rivaroxaban & 1.23 for apixaban) [126] - warfarin - INR of 2.0-3.0 is therapeutic% - see risk factors for thromboembolism - anticoagulant of choice in patients with mechanical heart valve [147], or hypertrophic cardiomyopathy [1] - MKSAP19 notes warfarin is only FDA-approved agent for valvular AF [5] - reduces risk 50% [10] & lessens severity of stroke [9] - 50% of patients benefit from anticoagulation [32]; patients with < 2 risk factors for stroke will not benefit - risk of stroke on warfarin; - 1.6%/year mean age 71 [10] - 2.6%/year mean age 81 [17] - in elderly (> 75 years of age), stroke scores with poor predictive value [41] - in elderly (> 75 years of age), risk of hemorrhage is high - risk of major hemorrhage 10%/year - risk of life-threatening hemorrhage 5%/year, - risk of fatal hemorrhage 1%/year [17] - increased risk of intracranial hemorrhage associated with INR > 3.5, age > 85 - reduces overall mortality 4.5 vs 5.3 per 100 person years [10] - reduces risk of mortality, MI & stroke in patients with chronic renal failure stage 3 & higher without increased risk of hemorrhage [67] - treatment of choice in patients with chronic renal failure stage 5 [182] - increased risk of hemorrhage due to warfarin in patients with chronic renal failure [67,124] - increased risk of ischemic stroke (RR=2.6), hemorrhage (RR=2.4) but decreased mortality (RR=0.8) relative to no anticoagulation in patients with chronic renal failure (GFR < 50 mL/min) [136] - warfarin may cause more harm than benefit in patients with end-stage renal disease [71] - warfarin of no benefit in preventing thromboembolism when GFR < 15 mL/min/1.73 m2 [124] - low risk of bleeding (2%), in elderly [25] aspirin> - risk or bleeding inversely associated with kidney function in older adults [90] - ineffective, even harmful in patients with ESRD [107] - risk schemes to predict warfarin-associated hemorrhage described in [43,53] - warfarin may paradoxically increase risk of ischemic stroke during initiation of therapy by inhibition of endogenous anticoagulants [62] - addition of aspirin to warfarin may not reduce risk of myocardial infarction in patients with stable coronary artery disease [84] - no data after cororary revascularization - restart warfarin 7 days after major gastrointestinal bleed - not associated with increased risk of GI bleed [104] - associated with reduced risk of thromboembolim & mortality relative to restarting at 30 days [104] - comparisons of direct oral anticoagulants with warfarin - stroke rate similar for dabigatran, rivaroxaban & warfarin, regardless of comorbidites [144] - rivaroxaban with higher rate of major hemorrhage than dabigatran & higher rate of GI bleeding than warfarin in patients with comorbidites [144] - mortality lower with dabigatran & rivaroxaban than with warfarin regardless of comorbidites [144] - apixaban & dabigatran more effective than warfarin in preventing embolic stroke; rivaroxaban & edoxaban with efficacy similar to warfarin - apixaban & edoxaban associated with less bleeding than warfarin; dabigatran & rivaroxaban similar to warfarin - factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) associatedwith less hemorrhagic stroke, intracranial bleeding, & lower all-cause mortality than warfarin [146] - rivaroxaban noninferior to warfarin for prevention of stroke or systemic embolism & is associated with less intracranial hemorrhage or fatal bleeding [5] - direct oral anticoagulants safer & more effective than warfarin for preventing reinfarction or bleeding in patients >= 75 years with prior stroke [174] - patients should continue anticoagulation during dental procedures & dermatologic procedures [56] * - CAUTION - concurrent use of SSRI with oral anticoagulants among patients with atrial fibrillation further increases risk of bleeding [194] === anticoagulation in renal failure === - warfarin - reduces risk of mortality, MI & stroke in patients with chronic renal failure stage 3 & higher without increased risk of hemorrhage [67] - treatment of choice in patients with chronic renal failure stage 5 [182] - increased risk of hemorrhage due to warfarin in patients with chronic renal failure [67,124] - increased risk of ischemic stroke (RR=2.6), hemorrhage (RR=2.4) but decreased mortality (RR=0.8) relative to no anticoagulation in patients with chronic renal failure (GFR < 50 mL/min) [136] - warfarin may cause more harm than benefit in patients with end-stage renal disease [71] - warfarin of no benefit in preventing thromboembolism when GFR < 15 mL/min/1.73 m2 [124] - apixaban - in patients with ESRD, apixaban associated with lower risk of major bleeding than warfarin, & with reductions in thromboembolism & mortality (dose 5 mg BID) [142] - not associated with benefit in patients with ESRD on dialysis [151] - alternative to warfarin in patients with end-stage renal disease [147] - safe with close monitoring in patients with ESRD on dialysis (MKSAP19) [5] === antiplatelet therapy === - see coronary stent for patients with atrial fibrillation who undergo PCI with coronary stenting - aspirin 81-325 mg PO QD - no longer recommended for prevention of thromboembolism in patients with atrial fibrillation [147,153] - continue low-dose aspirin with DOAC if MI in past year - formerly recommended for elderly with CHADS2 score of 1 [6] - when harms of anticoagulation in frail cognitively impaired elderly are deemed unacceptable, many receive aspirin rather than nothing [197] - ref [68] recommends changing warfarin to aspirin 81 mg QD for elderly with GI bleed, creatinine clearance 15-30 ml/min, INR therapeutic - renal dosing of dabigatran considered not indicated - no mention of apixaban - no mention of acid suppression with proton pump inhibitor - NSAIDs are associated with increased risks for bleeding & thromboembolism in patients with atrial fibrillation [83] - increased risk with or without anticoagulation [83] - clopidogrel no better than aspirin [19] - clopidogrel + aspirin - inferior to warfarin [24] - better than aspirin alone but associated with increased risk of GI bleed (see ACTIVE A trial) [29] - may be a reasonable alternative to aspirin alone in the occasional high-risk patient who cannot be treated with anticoagulation [68] - anticoagulation + P2Y12 receptor inhibitor (without aspirin) if coronary stent - anticoagulation alone for AF + chronic stable CAD [150] - warfarin plus antiplatelet agent substantially increases risk of bleeding, & risk outweighs any potential benefit [58] - for older adults with atrial fibrillation & acute MI who undergo PCI, treatment with dual antiplatelet therapy (DAPT) plus warfarin (triple therapy) of no benefit over DAPT alone & may increase risk of bleeding [96] === cardiac pacemaker === - sick sinus syndrome accompanying AF - symptomatic patients with paroxysmal AF === elective surgery === - target ventricular response for patients with chronic atrial fibrillation to undergo elective surgery is < 110/min [182] - see direct oral anticoagulant vs warfarin or perioperative anticoagulation if patient anticoagulated === diet & lifestyle changes === - weight reduction >= 10% in obese or overweight patients [95] - moderate physical activity can improve quality of life [154] - limit alcohol consumption as this may trigger or exacerbate atrial fibrillation [154] - no recommendation to discontinue alcohol [68] === prevention of atrial fibrillation === - control hypertension - control weight - smoking cessation - treatment of sleep apnea may be of benefit [130] - chocolate may be of benefit [130] - fish oil (840 mg of omega-3 fatty acids EPA/DHA) &/or vitamin D (2000 IU/day) of no benefit in preventing atrial fibrillation [165] - fish oil of no benefit in preventing post-operative atrial fibrillation === screening for atrial fibrillation === - palpating pulse most cost effective means [5] - USPSTF finds insufficient evidence to recommend for or against screening for atrial fibrillation with ECG [143] === wearable devices === - use of smartwatches or other wearable devices that measure pulse & detect arrhythmias is associated with increased follow-up health care use [167] === prognosis === - mortality for hospitalization due to AF = 1% [75] - recurrent atrial fibrillation occurs in 32% of patients with transient new-onset atrial fibrillation during hospitalization [185] - in-home nursing visit 7-14 days after hospital discharge with multidisciplinary support as needed [85] - does not prevent death or hospital readmission - shortens duration of subsequent hospitalization * aspirin may not be effective in patients > 75 years of age # in patients with WPW, rhythm control is indicated; procainamide is the drug of choice (see Wolf-Parkinson-White syndrome) % exception is rheumatic heart disease, INR=2.5-3.5 [5]

Interactions

disease interactions

Related

ablation for atrial fibrillation; pulmonary vein isolation/ablation Atrial Fibrillation Follow-up Investigator of Rhythm Management (AFFIRM) Atrial Fibrillation Suppression Trial (AFIST) atrial flutter cardiac conduction system cardioversion pharmaceutical agents for treatment of atrial fibrillation risk factors for thromboembolism associated with atrial fibrillation Wolff-Parkinson-White (WPW) syndrome

Specific

paroxysmal atrial fibrillation (PAF) postoperative atrial fibrillation; perioperative atrial fibrillation silent atrial fibrillation; atrial high-rate episodes

General

supraventricular arrhythmia chronic cardiac arrhythmia fibrillation

References

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Databases & Figures

OMIM correlations Figures/diagrams/slides/tables related to atrial fibrillation