Atrial Fibrillation

• Issues in Management of AF

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• Should We Maintain Sinus Rhythm?
• The AFFIRM trial
• The SAFE-T trial- amiodarone vs sotalol vs placebo

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• Anticoagulation in AF
  • Risk of Thromboembolism-CHADS2
  • "Moderate Risk" Patients
  • "High-Risk" Patients
  • Secondary Prevention
  • Target INR level for AF patients
  • Maintain INR in theurapeutic range

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• Clopidogrel
  • Anticoagulation slightly better than Clopidogrel with Aspirin
  • Clopidogrel with Asprin better than Aspirin alone for those not eligible for anticoagulation

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• Cardioversion
• Role of Transoesophageal Echo in Cardioversion

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• Use of ACE-inhibitors or ARBs
• ACE-inhibitors may reduce the risk of recurrent PAF in those with lone PAF

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• Non-Pharmacological Therapy
• Options

Risk of Thromboembolism in Non-Rheumatic Atrial Fibrillation

ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. J Am Coll Cardiol 2001;38:1231–65) Thromboembolic Risk in Chronic Atrial Fibrillation
High Risk	Moderate Risk	Low Risk
see below for SPAF III and AFFIRM trials' criteria	No high risk features	No high or moderate risk features and aged less than 65 years
	Those who would otherwise be at low risk but are aged more than 65 years
	Probably includes those without high risk features but with well controlled hypertension or with IHD or with diabetes

High Risk: Comparison of AFFIRM and SPAF III entry criteria
AFFIRM (all at least 65 years of age (average 70 years) and with at least one of the following:	SPAF III (average age~71 years) with at least one of the following:
Hypertension	Systolic pressure greater than 160mmHg
Congestive heart failure	Congestive heart failure
Ejection fraction less than 40 percent	Poor LV systolic function
LV fractional shortening less than 25%	LV fractional shortening less than 25%
Prior TIA or stroke	Prior thromboembolism
LA greater than 5.0cm
	Females aged over 75 years

The CHADS2 scoring system is one of the more recent attempts to estimate the risk of stroke. The table below describes the factors that are assessed to derive the score.

Risk Factors	Score
C- recent Congestive heart failure	1
H- Hypertension	1
A- Age>75 years	1
D- Diabetes	1
S2- Stroke or history of TIA	2

The risk of stroke increases with higher scores. High risk can be defined as a CHADS2 score of three or greater. However, those with lower score are still at "moderate risk" and may obtain significant benefit from anticoagulation therapy.

Hitesh Patel, Cardiologist
19th March, 2007