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Atrial Fibrillation
What is New in the 2006 ACC/AHA/ESC Guidelines
HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation. May 2007
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AF: Points of Focus
•Classification, epidemiology, and mechanisms•Consequences of AF and aims of therapy•Anticoagulation•Rate control•Rhythm control•Rate vs. rhythm control: What to do?•Catheter ablation for AF: What is the current status
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AF: Classification•First detected episode•Recurrent AF (after 2 or more episodes)
–Paroxysmal (spontaneous termination)–Persistent (lasting beyond 7 days, or termination with drugs or
DCCV)
•Permanent AF: Sinus rhythm can not be restored
•Lone AF: Pts. younger than 60. No clinical or echo evidence for cardiac disease
•Nonvalvular AF: Cases without RMV disease, prosthetic heart valve, or valve repair.
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AF Definition
•Paroxysmal AF: Recurrent AF (2 episodes) that terminates spontaneously within 7 days.
•Persistent AF: AF which is sustained beyond seven days, or lasting less than seven days but necessitating pharmacologic or
electrical cardioversion.
•Longstanding persistent AF: is defined as continuous AF of greater than one-year duration.
•Permanent AF: Sinus rhythm could not be restored and a decision has been made not to pursue restoration of sinus
rhythm by any means, including catheter or surgical ablation.
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AF: Prevalence and Incidence
•Prevalence:–0.4% - 1% in the general population–8% in population over 80 years old–Lone AF: Less than 12% of all AF cases
•Incidence:–0.1% per year in people < 40 years old–2.0% per year in men > 80 years old–10% is the 3-y incidence in HF patients
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0
10
20
30
Wolf et al. Stroke 1991;22:983-988.
50–59 60–69 70–79 80–89
AF: Prevalence and StrokesThe Framingham Study
AF: Prevalence and StrokesThe Framingham Study
%
AF prevalence Strokes attributable to AF
Age Range (years)
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AF: Common Clinical Causes
Cardiac causes
•Hypertension•Coronary artery disease•Congestive heart failure•Pericarditis/Myocarditis•Valvular heart disease
Non-cardiac causes
•Electrolyte disturbances•Thyroid dysfunction•Ethanol intoxication•Vagal/sympathetic imbalance•Pulmonary disease•Sepsis, febrile illness
Appropriate work-up should be done and reversible causes identified and treated7
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AF: MechanismsAF: Mechanisms
•Rapidly firing atrial foci (hyperexcitability)•Macroreentry with fibrillatory conduction
(mother wave)•Multicircuit reentry
Remodeling acts to make multicircuit reentry a common final pathway
Nattel et al. Ann Rev Physiol 2000;62:51-77.
Multicircuit reentry(Mines, Garrey)
Mother wave(Lewis)
Hyperexcitability(Engelmann, Winterberg)
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