Atrial fibrillation/flutter: When to refer, What tests, What meds

Transcription

1 Atrial fibrillation/flutter: When to refer, What tests, What meds Warren Smith Green Lane Cardiovascular Service Auckland City Hospital, Auckland, New Zealand

2 Why might it not be a good idea to cardiovert this 59yr old man with incidental atrial fibrillation on candesartan 8mg for hypertension?

3 Atrial fibrillation/flutter: when to refer, what tests, what meds Rate-related cardiomyopathy develops quickly Titrate rate-control drugs every 2 4 days LA size >35cm 2 discouraging to cardioversion Fix atrial flutter early with cardioversion or ablation Consider sotalol or flecainide post cardioversion

4 Take Home Message Everyone deserves one shot at sinus rhythm

5 Referral date 12/03/ yr old male Atrial fibrillation/flutter Poorly controlled rate with symptoms Shortness of breath Seen today with a few days of tiredness but denies palpitations or chest pain. Legs puffier than usual and a bit of SOB with talking. Appears to have NEW AF not recognised before. Confirmed on ECG Rate fast 128. creps in bases. egfr last year normal (repeating again today) normotensive. Started on dabigatran and frusid and diltiazem for rate control. Rarely attends Dr Impression NEW AF with CHF. Please see for assessment/echocardiogram and consider DC shock etc thanks

6 Echo 26/3/2015 Normal LV cavity size LV function - moderate-severe globally reduced LV fraction calculated ejection fraction 33% LA area 30cm 2 RA 33cm 2 Mild-moderate RV global dysfunction

7 DC cardioversion 10/4/ J

8 Echo 01/5/2015 (36 days later) Normal LV size LV ejection fraction is low normal Calculated ejection fraction 52% Probably moderate LV diastolic dysfunction Reviewed 14/5/2015 and metoprolol changed to sotalol 80mg B.D.

9 Take Home Message Rate-related cardiomyopathy comes on quickly and goes away quickly

10 Persistent AF 28/4/2015 Discharged from hospital on metoprolol 47.5mg + diltiazem 120mg. Heart rate 152/min walking half the length of the Mercy corridor Seen 29/4/2015 double metoprolol to 95mg 63 yr old male Perimount AVR + LIMA 15/04/2015 Seen 6/5/2015 heart rate 145/min walking corridor, add extra metoprolol 47.5mg

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12 Metoprolol increase further to 190mg

13 Why not Cardiovert? Not on warfarin, 2 previous GI bleeds needing 6U & 4U transfusion. Current Hb 81g/L

14 Take Home Message Serial assessment to optimise rate-control important. Reasonably large dose of betablocker and calcium blocker may be necessary.

15 65 yr male Inveterate runner, 1st seen March 2015 Excessively puffed after minutes, likely in AF since November Check Holter for heart rates during exercise, echo (LA 33 cm²) Start dabigatran 150mg BD

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18 DC cardioversion 13/5/ J

19 Take Home Message Check rate control high vagal tone precluded need for rate slowing medication. Important to start rhythm control drug post cardioversion

20 Referral date 27/03/ yr female No SOB. BP 120/70 irregular rate JVP elevated although hard to read Bilateral ankle oedema Stop aspirin, start dabigatran 150mg B.D. HAS BLED score 1

21 Seen at my clinic 14/5/2015 Heart rate controlled on atenolol 50mg B.D. No evidence of heart failure on 50mg frusemide Dabigatran not tolerated warfarin Although her age and left atrial size (31cm 2 ) predicts a strong likelihood of early return of atrial fibrillation nonetheless I think one attempt at cardioversion is reasonable.

22 DC cardioversion 12/6/ J

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26 Take Home Message Atrial fibrillation may be associated with sick sinus syndrome and rate slowing drugs will aggravate this cardioversion occasionally has a nasty surprise

27 Why might it not be a good idea to cardiovert this 59yr old man with incidental atrial fibrillation on candesartan 8mg for hypertension?

28 Nearly everyone deserves one try at cardioversion

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