“first episode” vs. Recurrant

Atrial fibrilationinformation sources: Hurst’s THE HEART and UpToDate articles

titled:

New Onset Afib and Cardiovascualr Effects of Obstructive Sleep Apnea

Afib or Aflutter?

Types

• Paroxsysmal: <7 Days (usually <24h)

• Persistant: > 7 Days• Requires pharmacologic or electrical

cardioversion

• Permanent• Failed Cardioversion• Stretch receptors in LV: direct relationship

Work up & DDx

• Rule out potentially reversible causes• Hyperthyroid• Electrolyte abnormalities• Holiday Heart Intoxication• Acute Ischemia (cath lab)• Infection• Acute Pericarditis

• Irreversible causes• Renal failure• CHF: Echo

Treatment of AFib

• No one ideal therapy for all patients• No therapy, allow A Fib• Anticoagulation (Coumadin)• Rate Control (Metoprolol, diltiazem, digoxin)

<110 bpm• Rhythm Control (Amiodarone, Flecainide, Sotolol)

• AV node ablation

• Cardioversion • Electrical• Pharmacologic: ex: Irbesartan (ARB), Procainamide,

and other Rhythm control drugs

Indications for EmerGent Cardioversion

• Active ischemia

• Evidence of organ hypoperfusion

• Pulmonary edema

• Atrial Tachycardia (rate >250 bmp) • Accessory pathway

• <48hours: Heparin• Unless CHADS2 score 0-1

Cardiovascular effects of

Obstructive Sleep Apnea

The connection

• Patients with OSA have increased prevalence and incidence of Systemic HTN• Apnea Hypopnea Index: >15 events/hour = 3x

the HTN

• More severe the OSA= More severe HTN

• Treatment with CPAP can lower Systemic BP• But not enough to avoid antihypertensive

medications

Further implications

• Corresponding daytime hypoxia (ex: COPD) • or excessive daytime sleepiness (with continued

hypoxia/hypercapnea from naps)

• = Worse Cardiovascular effects from OSA

• And possible Pulmonary Hypertension

• Association with Severe OSA and CAD• Cause or effect??

• Clear studies that OSA worsens CHF

OSA And Arrhythmia

• Unclear cause vs. effect relationship

• >30 events/hour, pts had increase in:• Nocturnal Atrial Fibrilation• Nonstustained nocturnal VTACH

• In patients with AFIB and Untreated OSA, AFIB is more likely to reoccur after cardioversion• 82% vs. 42%

What to do about it?