how can a patient be managed having Atrial Fibrillation with rapid ventricular response ?
Hi Zarak,
The cornerstones of atrial fibrillation (AF) management are rate control and anticoagulation and rhythm control for those symptomatically limited by AF. The clinical decision to use a rhythm-control or rate-control strategy requires an integrated consideration of several factors, including degree of symptoms, likelihood of successful cardioversion, presence of comorbidities, and candidacy for AF ablation .
Restoration of sinus rhythm with regularization of the heart's rhythm improves cardiac hemodynamics and exercise tolerance. By maintaining the atrial contribution to cardiac output, symptoms of heart failure and overall quality of life can improve. As AF contributes to pathologic atrial and ventricular remodeling, restoration of sinus rhythm can slow or, in some cases, reverse atrial dilatation and left ventricular dysfunction. For these reasons, most clinicians focus initially on restoration and maintenance of sinus rhythm in patients with new-onset AF and opt for a rate-control strategy only when rhythm control fails.
Initial treatment is directed at controlling the ventricular rate, most often with a calcium channel blocker, a beta blocker, or digoxin. Medical or electrical cardioversion to restore sinus rhythm is the next step in patients who remain in atrial fibrillation. Heparin should be administered to hospitalized patients undergoing medical or electrical cardioversion. Anticoagulation with warfarin should be used for three weeks before elective cardioversion and continued for four weeks after cardioversion.
AF with fast ventricular response and hemodynamic compromise as in pre excitation syndrome requires synchronised Electrical cardioversion. Most patients with AF can be managed with rate control strategy, using an AV blocking drug. Beta blockers, Digoxin and nòn DHP calcium channel blockers ( Verapamil and Diltiazem) are the options. The preferred drug for rate control is beta blocker as it controls the heart rate both during rest as well as exercise. Verapamil and Diltiazem should be avoided in presence of heart failure. Rhythm control is preferred in selected group of patients based on multiple factors like presence of structural heart disease, left ventricular function, hemodynamic status and ventricular rate during paroxysms of AF. Intravenous Amiodarone and Ibutilide are good for conversion to sinus rhythm. In people without structural heart disease, Class I C drugs are good options for conversion to sinus rhythm. Young patients with recent onset or paroxysml AF and in whom maintenance of sinus rhythm is likely, ablation is an attractive option. AF with very fast ventricular rate even after initiating combination of AV blocking drugs can be considered for AV node ablation or AV node modification. Long term anti coagulation to prevent thrombo embolic episodes is required in most patients based on the risk stratification.
Hi Muhammad,, all most everything have been discussed. Acute AF with haemodynamic compromise needs cardioversion. Acute AF in haemodynamically stable patient conversation to sinus rhythm can be done with intravenous amiodarone and ibutilide. Oral propafenone can be also used in structurally normal heart. For chronic persistent AF, rate controll is better than rhythm control. Rate controll can be done with digitalis, betablockers and calcium channel blockers. Ranolazine is also showing promise in maintaining and converting sinus rhythm in patients of refractory AF, thought well designed trial is needed.. Thanks
Hi Muhammad,,, continuing the discussion.. Vernakalant is a class 111 Antiarrhymic drug is very effective in conversion to sinus rhythm in patients of AF.. Thanks
There are also other possibilities of sudden onset of tachyarrhythmias, with (often) different choice of specific treatment:
1. thyrotoxic storm in an acute onset or unexpected aggravation of Graves-Basedow disease due to various external (viral) or internal (autoimmune)
causes,
2. Sudden appearance (or acute aggravation of hitherto unrecognized ) sinus node failure when tachyarrhythmia is an escape and protective natural answer ( noli me tangere, except slowing of ventricular answer).
"There are not diseases, there are only patients" (Claude Bernard)
I support the idea:
the patient can help with their own thoughts for his treatment...
1. Lanoxine. 2. Bisoprolol. 3. Verapamil. 4. Amiodarone allowed if rate is still high in spite the above. 5. Correct anaemia, thyroid function, anxiety, obesity, smoking, cardiac valve or muscle disease. 6. Assurance that rate up to 80 at rest and 110 at effort is accepted.
Continuing the discussion,, digoxin is used mainly in patients with AF with heart failure. In India,, still a quite large number of patients with AF gets digoxin because it is very inexpensive. However it should be very causously used in elderly, renal failure patient and hypokalemia to be avoided.
Digoxin is also very effective along with betablocker for controlling rate in AF in patients of mitral stenosis which is quite common in India. In majority of cases only betablocker can not control rate of AF in mitral stenosis.. Thanks
Controlling ventricular rate is critical in patients with mitral stenosis. Reduced diastolic filling period significantly increases LA pressure. Combination of beta blockers with Digoxin is required for rate control in many much patients, as has been rightly pointed out. Verapamil and Diltiazem for rate control should be avoided in MS patients with right ventricular systolic dysfunction.
Hi Muhammad, Ranolazine an antianginal agent has shown promise in management of AF specially in maintaining sinus rhythm.. Following link might help you.. Thanks
Nothing to add but in case of pre-excited AF DCC is the only option.
Electrical cardioversion is still a relevant and potent option especially of there is no significant hemodynamic compromise.
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