Choice anti arrhythmic drugs for AF in pt with CKD:

 Amiodarone would be safe as it is mainly metabolized in liver but outweigh thr long term side effects
of its use particularly Corneal deposit, liver toxicity and lung interstitial disease.
 Sotalolol can be used but not recommended if cr cl less than 40ml/min
 procainamide can be used but if crcl less than 40 ml/min dose reduction with increased duration of
intervals every 12 hours
 Flecainide mainly execreted in kidney and dose reduction with increased time intervals
recommended if crcl less than 40ml/min to be used 25-50mg BID.

When Digoxin is not used to control ventricular rate in atrial fibrillation:

1-If there is Pre-excitation like WPW syndrome
2-Patient who Has AF with any degree of Heart block
3-Patient known to have Cardiac Amylodosis cause it adhere to Amyloid protein and increase toxicity
4-Patient with Acute critical illness
5-Advanced kidney disease
6-Patient with Hepatitis or Liver dysfunction
7-In presence of Electrolytes disturbance mainly Hypokalemia as it increase risk of toxicity

 RBBB with AF = Ebstein’s anomaly / ASD

 LBBB + AF = DCM or MS or Ischemia
AF:
 Absent a wave (no atrial contraction, no atrial kick)
 Absent x descent (no atrial relaxation phase due to fibrilation)
 Bleeding per rectum + AF + metabolic acidosis >>> Ischemic colitis
 Procainamide as well in Rapid AF with pre-excitation syndrome.
 Avoid any Av Nodal Av blocking agent that might precepitate VT and VF.
 Keeping in your mind, if you co-adminster amiodarone with digoxin, you have to reduce the dose of
digoxin by 50-70%.
What is the target VENTRICULAR RATE in medical rate control of AF ?
 Lenient strategy : 110 resting with success rate 98%
 Strict strategy: 80 resting & 110 ambulatory with success rate 68%
 Patients with Atrial Fibrillation with RVR have distorted ST Segments

AF: post-stroke key concepts

--> Ischemic, [after exclusion of hemorrhagic stroke] --> 14 days Aspirin then warfarin
--> TIA or small lacunar infarction --> Warfarin as soon as possible

Regardless CHA2Ds2VASC Score For AF, Anticoagulation Needed In:

 Peripartum Cardiomyopathy especially if EF less than 35% or if Bromocriptine added for 1 month.
 Antiphospholipid syndrome with recurrent thrombosis
 Controversial in Left ventricular aneurysm post MI particularly in those with reduced EF.

Management of AF in pregnancy
 Rate vs. Rhythm control?
Answer: Rhythm control is preferred over rate control to avoid side effects of the drugs(Rhythm control is
usually achieved by DC cardioversion).
 Drugs used for rate control:
-Selective B1 blockers(metoprolol or bisoprolo) (class I)
-Calcium channel blockers(Verapamil)(class IIa)
-Digoxin (class IIa)
 Drugs used for Rhythm control:
-Sotalol
-Propafenone or flecainide (for structually normal heart or pre-excitation)
NB:Amiodarone is contraindicated with pregnancy
 Drugs used for anticoagulation:
Either therapeutic weight based LMWH or warfarin based on stage of pregnancy
NB:NOACs are contraindicated in pregnancy and lactation

-First trimester:
LMWH or warfarin if dose less than 5mg
-Second trimester until 36 weeks:
Warfarin
-After 36 weeks to 36 hours before delivery:
LMWH
-36 hours before and After deliverly:
UFH infusion
(stop 6 hours before delivery)
 The decision for giving anticoagulation is based on CHADS VASc score

Conditions in which you should give anticoagulation in AF regardless of CHADS-vasc score:

HCM
Fontan
stemic RV
—————-
Intra-cardiac repair in congenital heart disease
Cyanotic heart disease
—————-
After ablation for 8 weeks
After cardioversion for 4 weeks
After LAA closure for 45 days
——————
Mechanical prosthesis
Moderate or severe MS
———————
Anticoagulation for other indications(DVT, PE, LV thrombus, etc)
————————
Thyrotoxicosis(in some papers)
Amyloidosis

Antiarrhythmic drug is not required to maintain sinus rhythm in patients with persistent atrial fibrillation in
whom a precipitant (such as chest infection, fever) has been corrected and cardioversion has been performed
successfully, provided there are no risk factors for recurrence.
In patients with persistent atrial fibrillation who require antiarrhythmic drugs to maintain sinus rhythm and
who do not have structural heart disease :
• a standard β‐blocker should be the initial treatment option
• where a standard β‐blocker is ineffective.
class Ic agent or sotalol should be given
• where other drug classes are ineffective, contraindicated or not tolerated, amiodarone should be given.

There is no well defined duration of antiarrhantiarrhythmic medications use and often it depends on the
likelihood of AF recurrence and it ranges from 1 to 6 months and in some cases It may be prolonged to 12
months.
It is clear from these trials that the use of antiarrhythmic drugs improves the maintenance of sinus rhythm
after cardioversion, but even despite treatment, relapse to atrial fibrillation occurs in approximately 50% at
12 months and a routine follow‐up to assess the maintenance of sinus rhythm should take place at 1 and 6
months after cardioversion.

CHADVASc score ‫ هو نحسب الـ‬next step ‫ ال‬،‫ ساعة‬48 ‫ و اقل من‬AF ‫من يجي‬
A. If was high, so we treat this case as chronic AF (AF > 48 hrs).
B. If it was low, and AF < 24 hrs: we give just rate control then "watchful waiting" for spontaneous
cardioversion. If there is no restoration of normal sinus rhythm, give amiodarone.
C. If was low and AF duration > 24 hrs but < 48 hrs: start witj rhythm control + periprocedual cardioversion.

Management of atrial fibrillation with bradycardia 60 associated with dizziness?

 Assess hemodynamics and organs perfusion
 Exclude any drug over dose or toxicity particularly Digoxin and BB
 Exclude underactivity of thyroid
 If the patient is hemodynamically stable, Watch and wait and the patient will be candidate for
Therapeutic anticoagulation based on CHA2DS2VASC score.
 Do basic routine investigations, ask about previous catheter ablation, ECHO screening for structural
Left atrial abnormality and we may need to do special tests in presence of suspicion of infectious
cause like lyme serology, Typhoid serology.
 If the patient is symptomatic Slow AF with no obvious correctable cause there may be possibility of
associated Sinus Node dysfunction or Sick sinus syndrome and this need help of electrophysiologist
and may warrant Pace maker implantation.

Indication of pharmacological cardioversion in Atrial fibrillation:

Recent onset, failed rate control, TEE is negative for atrial appendage thrombus.
In hemodynmically stable patient
You can cardiovert with just 5000 unit of IV heparin if
1-Onset of AF is clearly less than 48 hours
2-TEE done and showed no LAA thrombus
3- If the patient is alreadly on anticoagulation for the previous 3 weeks and INR is within the theraphetic
range

How do you deal with atrial fibrillation in septic shock?

In case of Non Cardiac related shock state especially septic shock , we understand this is an Extracardiac
cause that may either worsen the control of persistent AF or put the patient at risk for developing AF with
RVR.
Whatever , our main priority in such scenario as long as there is Extracardiac cause aggravating AF is to
identify and treat it appropriately.
Actually should the patient is not known to have persistent AF , He doesn't need to receive therapeutic
anticoagulation at first instance. Using rate control in such scenario may worsen the CO by giving Negative
inotropic drugs.
So initially optimize Hemodynamics and don't bother your self by AF with RVR. (Volume status , Vasopressor ,
avoid arrythmogenic inotropes , correct Anemia , Control fever , Correct Hypoxia , metabolic acidosis ,
electrolytes disturbance, Control the pain ). We deal with Sympathetic over activity with release of
inflammatory markers and so we in need to control it without worsening Hemodynamics.
Briefly in my opinion :
A) if the patient is Known To have Persistent or Paroxysmal AF , in view of shock state I would use Therapeutic
anticoagulation only with cautious use of Betablockers as rate control or Digoxin even if he was on
Vasopressor.
B) if the patient is not known to have AF and ECHO data wouldn't suggest any organic pathology, I just focus
on improving Hemodynamics and excluding Myocardial dysfunction or necrosis induced by inflammation
through Laboratory markers (ProNB, Cardiac enzymes ) if So, i would think about anti-Arrhythmic drug the
available is Amiodarone without need for therapeutic anticoagulation.
Consider DC shock if all measures fail to control HR despite optimizing volume status and other factors.

Management of antithrombotic agents in patients with carotid stenosis + atrial fibrillation for primary and
secondary prevention of stroke ?
if the patient fullfill criteria of NASCET to do CEA as he has got significant Carotid stenosis so the treatment
would be CEA within 2 weeks for both those who presented with recent non hemorrhagic stroke or being
asymptomatic adding to high dose statin and Antiplatelet (Aspirin)..
if the patient has No AF but significant Carotid artery Stenosis who will be candidate for CEA:
High dose statin +Aspirin 100-325 mg in acute stage then for life long secondary prevention of stroke,
Recommendation is to shift to Clopidogrel.
in case of there is Atrial fibrillation and being candidate for Anticoagulant, then the choice will be categorized:
1-Acute stage of Non hemorrhagic stroke with
-High dose statin + Aspirin dose 100-325 mg during hospital course and upto 2 weeks then we do shift for
lifelong
Anticoagulation (DOAC/Warfarin) which will be added based on severity of Stroke.
2-Asymptomatic Patient who will go for CAE or even deferred from surgery and has AF:
High dose statin +Aspirin +DOAC after outweighing the benefits vs the risks of bleeding.

Which factors prefers to uses dual : aspirin and NOAC After 1 year of ACS and Atrial fibrillation ?
» Usually the standard protocol in AF patients who went for PCI is to use Triple therapy for the shortest
period if the risk of. Thrombosis is high compared to bleeding risk ( up to first 4 weeks) then we shift the
patient on DOAC + P2Y12 inhibitor or Ticagrelor for high risk of thrombosis up to 1 year.
» According to studies no add on mortality benefit from combined Aspirin +DOAC after 1 year in PCI treated
patients with AF
(AFIRE Trial) And the risk of bleeding is High compared to DOAC only.. so most recommendations follow
Single DOAC after 1 year PCI.

Vernaklant doesnt have NICE recommendation to be used as Antiarrhythmic for cardioversion of AF and to
my knowledge evidence is scarce.
Indication of cardioversion:
1-Acute onset AF within 48 hours
2-Lone AF
3-Alcohol induced AF
4-AF with RVR due to pre-Excitation syndrome
Electrical Cardioversion as an emergency if the patient has presented with Hemodynamic instability and AF
with RVR.
Chemical cardioversion achieved by
» Amiodarone in structural Heart Disease
» Procainamide in case of Pre-excitation syndrome
» Flecainide
» Propafenone
if failed to restore Sinus rhythm in acute AF of duration less than 48 hours by chemical cardioversion»»
Proceed to Electrical Cardioversion.

Patients who are candidate for rate control in AF:

1-Those who are at risk of Ischemic CVS
2-Structural heart disease patients
3-Previous history of Valvular disorder (RHD)
4-Paroxysmal AF patient

Anticoagulation in new onset atrial fibrillation less than 24 hr

What if 24-48 hr
»Less than 24 hours (Optional) No need for therapeutic anticoagulation.
» if it lasts for more than 24 hours then provide therapeutic anticoagulation at least for short term 4 weeks
and according CHA2Ds2Vasc score we will discuss the need for Life long anticoagulation.
» If we are going to do elective cardioversion what ever the CHA2Ds2Vasc score we need to be 3 weeks on
anticoagulant and continue for 4 weeks after successful cardioversion.

The guideline on atrial fibrillation from the NICE recommends that people with atrial fibrillation who are at
risk of a stroke and who have been assessed for their bleeding risk should be prescribed a DOAC in
preference to a warfarin.
This reduction in intracranial haemorrhage is the most compelling reason to prescribe a DOAC over
warfarin.

Atrial fibrillation
➕ complete heart block = Regular atrial fibrillation OR Digoxin toxicity

»No rule for Antiplatelet in stroke prevention in patient with AF and The risks of bleeding was
higher.
» Only approved for stroke prophylaxis in AF is Anticoagulant with DOAC first choice in Non-Valvular
AF patients who fulfill CHA2DS2-Vasc score for Male> 2 and Female> 3

Indications of warfarin in AF?

» Stroke prophylaxis in case of presence of:
1-LV thrombus
2-APLS «Fulfill Obstetric and Thrombotic criteria»
3-Severe. Mitral stenosis
4-Prosthetic Heart Valve
5-Hypercoagulable state
6-Rheumatic Heart disease (Recent Trial in ESC concluded that risk of bleeding and recurrent
thrombosis markedly reduced with warfarin compared to DOAC in such case)

Consequences of AF in clinical examination

1-Pulse deficit more than 10(between radial and apical pulse)
2-Systolic expansion in neck veins
3-Variable S1
4-No S4
5-Loss of presystolic accentuation of mitral stenosis murmur
How to differentiate between AF with LBBB Vs Pre-excited AF Vs AF with non sustain VT
Pre-excited AF:
•Wide QRS complex, Irregular rhythm with Delta wave can be seen in chest leads.
•Rate usually exceed 200/min may with beat to beat variation in QRS morphology.
» AF with LBBB:
Wide QRS complex Irregular rhythm
LBBB criteria: Monophasic R in lead I, avl, V5 V6
some cases may see M shape pattern in. Lewd V6 (Not must)
deep S wave in V1
AF with non sustained VT:
•So initial rhythm will be Narrow QRS complex irregular rhythm
•Intermittently we will see Wide Regular QRS complex not preceeded by P wave seen lasting less
than 30 sec (Mostly 3-5 same shape QRS morphology).
In AF with pre-excitation»»» Wide> 0.12 sec
In AF with LBBB»»»»»»» Wide> 0.12 sec but rate lower with criteria of LBBB exist
In AF with non sustained. VT»»» Narrow QRS intermitgent with Non sustained VT complexes.

Guidelines agree on rate control as initial strategy for most patients, but rhythm control may be
preferred if persistent symptoms despite rate control, difficulty achieving adequate rate control,
younger age (such as age < 65 years), tachycardia-mediated cardiomyopathy, new onset atrial
fibrillation, atrial fibrillation precipitated by acute illness, heart failure exacerbated by atrial
fibrillation, preexcitation, pregnancy, or patient preference

Conditions in which you should give anticoagulation in AF regardless of CHADS-VASc score

1-HCM
2-Fontan
3-Systemic RV
4-Intracardiac repair in congenital heart disease
5-Cyanotic heart disease
6-After ablation for 8 weeks
7-After cardioversion for 4 weeks
8-Mechanical prosthesis
9-Moderate or severe MS
10-Anticoagulation for other indications(DVT, PE, LV thrombus, etc)
11-Thyrotoxicosis