ATRIAL SEPTAL DEFECT Dr. M. A. Sofi MD; FRCP (London); FRCPEdin; FRCSEdin.
NILOFAR RAHMAN, MD AMIT KUMAR, MD. DEFINITION A SVT with uncoordinated atrial activation with...
-
Upload
joseph-york -
Category
Documents
-
view
214 -
download
1
Transcript of NILOFAR RAHMAN, MD AMIT KUMAR, MD. DEFINITION A SVT with uncoordinated atrial activation with...
DEFINITION
A SVT with uncoordinated atrial activation with constant deterioration of atrial mechanical function
On EKGs it is defined by replacement of consistent P waves with rapid oscillations that vary in size, shape and timing ass. With an irregular RVR when AV conduction is intact.
CLASSIFICATION
PAROXYSMAL: Self terminates< 7 days, usu, within 24 hrs.
PERSISTENT: > 7 days, terminate spontaneously or by cardioversion
PERMANENT: > 1 YR, CV attempted or failed
LONE: Without any structural heart disease
ASSOCIATED DISEASES
HTN: 1.4 fold increase risk
CHD: when complicated by acute MI or heart failure CASS trial: RR was 1.98 in 7 yrs
VALVULAR HEART DISEASE: MS, MR, TR: 70% RISK MS, MR: 52% ISOLATED MS: 29%
HYPERTROPHIC CMP:
CONGENITAL HEART DISEASE
OTHERS: hyperthyroidism, PE, COPD, lupus myocarditis OSA: reduced reccurence with treatment
CLINICAL MANIFESTATIONS
SYMPTOMATIC OR ASX EVEN IN SAME PT.
PALPITATION/CP/DYSPNEA/FATIGUE/LIGHTHEADEDNESS/SYNCOPE
EMBOLIC COMPLIC. OR HEART FAILURE
POLYURIA: ANP
ASS. RVR- CMP
EVALUATION
H&P:
EKG: verify AF
CXR: lungs, vasculature and cardiac outline
ECHO TTE: size and function of chambers, valvular heart diseases TEE: thrombi in left atrium
TSH
ADDITIONAL TESTING: EXERCISE TEST HOLTER/EVENT MONITOR
GENERAL PRINCIPLES OF TREATMENT
RHYTHM CONTROL•CONVERSION TO NSR•MAINTAINENCE
RATE CONTROL•MEDICATION
•RADIOFREQUENCY ABLATION CHOOSING B/W RATE AND RHYTHM CONTROL
PREVENTION OF SYSTEMIC EMBOLIZATION
RATE VS. RHYTHM CONTROL
AFFIRM AND RACE TRIALS: 2 CONCLUSIONS-
Embolic event occur in equal frequency
lower incidence of primary end point with rate control strategy
TREATMENT
RATE CONTROL
• Beta blockers
• Calcium channel blockers
• Digoxin
• GOALS: HR<80 bpm, 24 hr. Holter average <100 bpm, HR < 110 bpm in 6 min. walk
• Non pharmacologic method: radiofrequency ablation and pacemaker implantation
RHYTHM CONTROL
PHARMACOLOGIC
DIRECT CURRENT CARDIOVERSION
Anticoagulation for 3-4 weeks before CV
Anticoag for 1 month after CV
usu done in hemodynamically unstable pts.
success rate is 75-93%, inversely related to atrial size and duration
…contd. RHYTHM CONTROL Maintenance of NSR:
20-30% maintain NSR > 1 yr. w/o antiarrythmics
duration of <1 yr, atrial size < 4 cm.
reversible causes
Amiodarone is known to be most effective
CTAF and AFFIRM trials
Flecainide and propefenone in those without heart disease
ANTICOAGULATION IN AF
RISK OF STROKE IS 3-5% WITHOUT ANTICOAGULATION
CHADS2 SCORE
SCORE OF 0: ASA
SCORE 1-2: ASA/WARFARIN
SCORE > 2: WARFARIN, INR GOAL 2-3
DABIGATRAN
APPROVED IN 10/10
RE-LY TRIAL EVALUATED SAFETY OF 2 DOSES
RESULTS:
Rate of stroke was lesser High dose - more effective than warfarin
Risk of bleeding was lesser in low dose
All-cause mortality was reduced
DISADVANTAGES
Twice dosing
High cost
Lack of an antidote
Dose adjustment for those with CKD
lack of long term safety data