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Atrial fibrillation (Treatment (Restoration of sinus Rhythm…

- - - - contraindications
        
        Relative
        • Severe LA enlargement (>5.5 cm)
        • Uncorrected valvular disease
        • Uncorrected hyperthyroidism
        • Short periods of sinus rhythm after prior ECV
        
        Absolute
        • Digitalis intoxication
        • hypokalaemia
      - depolarization of myocardial cells with direct electrical current, synchronized with the R wave, in short general anesthesia. Patient has to be on an empty stomach.
        
        Effectiveness of ECV is 70-90% and higher, if:
        o AF is short-lasting
        o LA is not enlarged
        o no organic heart disease is present
        o patient does not present emphysema nor obesity
        
        Biphasic current 100-200 J
    - - novel oral anticoagulants
        
        DABIGATRAN
        
        Direct thrombin inhibitor, oral administration
        
        not metabolised by CYP 450 - few interactions
        
        no need for INR monitoring
        
        RE-LY trial ???
        
        Rivaroxaban
        
        Selective, direct Xa1 inhibitor
        
        High bioavailability with oral administration (80-100%)2
        
        Fast onset of action
        
        Half-life: 5-9 hours in the young, 11-13 hours in the elderly
        
        Anticoagulation effect 24 hours
        
        Double elimination route: 1/3 renally, 2/3 is metabolised in liver
      - AF up to 48h – conversion without preparation
        AF >48h – conversion after preparation
        Acenokumarol, Sintrom, Warfarin (INR 2,0 – 3,0) or Dabigatran
        for 3 weeks before and 4 weeks after cardioversion
        because of the risk of LA thrombus
      - transesophageal echocardiography (TEE)
        to skip the need for 3-week long anticoagulation before cardioversion,
        to exclude LA thrombus
        4-week long anticoagulation after cardioversion is still mandatory!!!
      - Chronic anticoagulation
        Each form of AF (paroxysmal, persistent, long-lasting persistent, permanent!!!)
        with risk factors of thromboembolic complications
      - CHA2DS2–VASc scale
        
        C – chronic heart failure 1pt
        H – hypertension 1pt
        A2 – age ≥75 years 2pt
        D – diabetes 1pt
        S2 – stroke/TIA/embolism 2pt
        V - cardiovascular disease 1pt
        A - age 65-74 years 1pt
        S - female sex 1pt
        
        estimating the risk of stroke in patients with atrial fibrillation.
        
        score of 2 requires oral anticoagulation and a score of 1 merits consideration for oral anticoagulation or aspirin. A score of 0 should not require any antithrombotic prophylaxis.
    - - Pills in the pocket:
        In case of an AF episode the patient takes himself: Propafenone 450-600 mg or Flecainide 200-400 mg
      - VERNAKALANT
        
        blocker of atrial channels: early activated K-channels and rate-dependent Na channels.
        
        more effective than amiodarone in restoration of SR within 90 min from drug administration.
        
        Dose: 3 mg/kg i.v. in 10 min
        
        contraindications: SBP < 100 mmHg, heart failure ( NYHA 3/4), ACS < 30 days, sever aortic stenosis
    - - If AF is hemodynamically unstable – immediately!
        
        First episode of AF in patient’s life
        
        AF worsening heart failure symptoms
        
        AF with severe symptoms, despite good ventricular rate control (EHRA > 2)
        
        AF secondary to other causes (hyperthyroidism, coronary artery disease), if the primary cause has been corrected/removed
- - - - excess adrenergic stimulation.
        
        Atrial fibrosis (RAA system)
        
        inflammation ( increase CRP with no cause)
        
        genetic ( connexion gene mutation)
        
        electrolytes imbalance
        
        stimulant (alcohol, coffee, amphetamine, cannabis, nicotine)