Heterogeneity Of AFNot all AF are the same!!!!!!

Dr.Mervat Aboulmaaty Prof. of cardiology Ain Shams university 2008

Heterogeneity Of AFNot all AF are the same!!!!!!

Heterogeneity Of AFNot all AF are the same!!!!!!

AF with fast vent response & aberrancy

AF with controlled vent. response

AF WITH LBBB

AF with IVCD

AF regular because of VT

Atrial Flutter/AF

AF and AT Flutter

AF WITH SLOW VR

AF with CHB

AF with WPW syndrome

AF with WPW syndromeAF degenerating to VF

AF in Patient with CHF and CRT

AT Flutter and 1:1 conduction

After CV A-Pacing Native Conduction

AF HeterogeneityPrevalenceAF prevalence doubling with each

decade◦0.55 at age 50-59 years◦ 9% at age 80-89 years

3-fold increase in men New onset AF: men are 1. 5

times as likely as women to develop it

Incidence of AF in Men and Women

Associated conditions with AFReversible Causes of Atrial

Fibrillationalcohol intake (“holiday heart

syndrome”), surgery, electrocution,MI, pericarditis, myocarditis, PE, pulmonary diseases, hyperthyroidism with Atrial flutter, WPW,AVNRT, AVRT complication of cardiac or thoracic

surgery

Associated conditions with AFAcute and chronic coronary

diseaseHTN Hypertrophic ,dilated &

restrictive CM ASDValvular Rheumatic 40% MS 75% MR

Cardiac conditions increasing the risk of AF

Men Women

20% 31%

HF 4.5% 5.9%

Valve disease 1.8% 3.4 %

Myocardial infarction

40% 20%

Atrial Fibrillation Without Associated Heart Disease lone AFLone AF before age 60 yrs without HTN or

overt structural HD (clinical exam, ECG and echo)

30% to 45% of paroxysmal AF and 20% to 25% of persistent AF occur in

younger patients without underlying diseaseAF can present as an isolated or familial

arrhythmiaIn elderly,

◦ myocardial stiffness may be associated with AF, ◦ Heart disease may be coincidental and unrelated

to AF.

AF and autonomic influenceVagal predominance in the minutes

preceding the onset of AFVagally mediated AF occurs at night or after

meals Cholinergic agents such as disopyramide

are helpful to prevent recurrent vagally

mediated AF Adrenergically induced AF occurs during daytime in pts with organic HDBeta blockers for adrenergically induced AF

Autosomal dominant hereditary AF Mapping analysis of the AF family

ECG and missense mutation

DNA and amino acid sequence of KCNQ1 missense mutation associated with affected members in the AF family. DNA sequence analysis revealed an A to G substitution causing an S140G mutation in the S1 segment of KCNQ1.

AF family with an autosomal recessive inheritance pattern

AF in the family manifests with early onset at fetal stage and is associated with neonatal sudden death

Some cases ventricular tachyarrhythmias and cardiomyopathy.

Heterozygous carriers have significant prolongation of P-wave duration compared with non-carriers

The maximum multipoint LOD score of 4.10 was obtained for 4 markers: D5S426, D5S493, D5S455, and D5S1998.

Circulation. 2004;110:3753-3759

Genetic map with chromosome 5p13 markers and locationof putative arAF1 gene

Patterns of AF

Mechanisms of AF

Rapidly firing atr automatic foci PV triggersAnatomical substrate for reentry within the PV

Symptoms of AFEmbolic complicationExacerbation of HFPalpitations, chest pain, dyspnea,

fatigue, lightheadednessSyncope.

◦upon conversion in patients with SSS◦ rapid ventricular rates in patients with HCM,

AS, WPW Polyuria with the release of ANP as

episodes of AF begin or terminate. Tachycardia-mediated cardiomyopathy

Pharmacological and non pharmacological Treatment

Drugs and ablation are effective for both rate and rhythm control

Ryhtm control vs Rate control For rhythm control, drugs are typically the first

choice and LA ablation is a second-line choice ( symptomatic lone AF young pts , no structrual HD)

RF ablation for WPW, AVRT, Atrial FlutterRF ablation in association with cardiac surgery

face a unique opportunity during MV Replacement, LAA obliteration

Standalone Surgical procedure (maze III or LA ablation)

Oral, H. et al. N Engl J Med 2006;354:934-941

Circumferential Pulmonary-Vein AblationRF Pulmonary Vein Isolation

“Ablate and pace” strategy that often yields remarkable symptomatic relief ( the negative effect of long-term RV) BIV Pacing

Atrial pacing, either in RA alone or Biatrial to prevent recurrent paroxysmal AF in pts with Bradycardic indication for Pacing (SSS AAI vs VVI)

Atrial pacing IS Not a primary therapy for prevention of AF

Atrial defibrillators for patients with LV dysfunction who are candidates

for implantable ventricular defibrillators

Pharmacological and Non-Pharmacological Treatment

Mortality and Morbidity with AFDeathAF Increases Mortality with AMIAF Increases mortality 50% Men 90% WomenHighest death 1st yr after AF diagnosisStrokeRisk 35% 1.5% at age 50-59 y23.5% at age 80-89AF+HF+CAD increase risk of a stroke 2

fold

Risk of StrokeCHADS2 Risk Criteria Score

◦Prior stroke or TIA 2◦Age 75 y 1◦Hypertension 1◦Diabetes mellitus 1◦Heart failure I

aspirin (325 mg) associated with 44% stroke rate reduction

Warfarin 50% more effective than aspirin for prevention of ischemic stroke

Thank youعليكم السالم

AF in Patient with CHF and CRT

General schema representing AF mechanisms

Predictors of AFHTN and DM were significant

independent predictors of AF increasing the risk 1.5 fold. (Framingham Study)

HTN is responsible for more AF (14%) than any other risk factor

Predictors of AFIndependent ECHO predictors of AF :

◦LA enlargement, ( 5mm AF 39%)

◦LV fractional short. ( 5% AF 34%)

◦LV wall thickness ( 4mm AF 24%)

ECG evidence of:◦ LVH was also a powerful age adjusted

predictor

Mortality results

0

5

10

15

20

25

Cum

ulat

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mor

talit

y (%

)

Year 1 Year 2 Year 3 Year 4 Year 5

Rhythm control Rate control

N Engl J Med 2002;347:1825-33.