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Tachycardia: Difference between revisions
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====Management:==== | ====Management:==== | ||
=====Acute Management:===== | =====Acute Management:===== | ||
The acute management of AF depends on the presentation of the patient. In stable patients with little complaints, rate control can be initiated with beta-blockers, non-dihydropyridine Ca-antagonists and digoxine. If the patient has recent onset of AF, is highly symptomatic or hemodynamicly compromised, cardioversion is indicated. Cardioversion can be performed medically or with electricity. Most effective drug is flecainide, although this drug is contra-indicated in patients with structural heart disease. Another optien is Ibutilide, but this is mostly used to terminate atrial flutter, and has a small change of ventricular arrhythmias. In patients with severe structural heart disease amiodarone can be given. Electrical cardioversion can achieved by a DC shock after sedation of the patient. If the AF persist for longer than >48 hours or the start of the episode is not clear, anti-coagulation should be initiated before (medical or electrical) cardioversion. Three weeks of anti-coagulation is advised before cardioversion and it should be continued after cardioversion for 4 weeks to minimize thromboembolic risk. | |||
=====Long-Term Management:===== | =====Long-Term Management:===== | ||
The management of AF consist of several key targets. Firstly, any underlying potential reversible cause of AF should be treated. Secondly, care should be taken to prevent the complications of AF. This means that adequate oral-anticoagulation should be initiated and rate control should be started to reduce heart rate. Thirdly, symptoms should be treated with medical or invasive therapy. There are two strategies to reduce symptoms of AF. Rate control is a strategy were a reduction of ventricular heart rate is the main goal. In rhythm control the aim is to maintain sinus rhythm and prevent recurrences of AF.<Cite>Camm2012,Camm2010</Cite> | The management of AF consist of several key targets. Firstly, any underlying potential reversible cause of AF should be treated. Secondly, care should be taken to prevent the complications of AF. This means that adequate oral-anticoagulation should be initiated and rate control should be started to reduce heart rate. Thirdly, symptoms should be treated with medical or invasive therapy. There are two strategies to reduce symptoms of AF. Rate control is a strategy were a reduction of ventricular heart rate is the main goal. In rhythm control the aim is to maintain sinus rhythm and prevent recurrences of AF.<Cite>Camm2012,Camm2010</Cite> | ||
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*** <b>Surgical treatment:</b> Surgery is a more invasive, but effective modality to treat atrial fibrillation. The classical cut and sew Maze procedure is a open chest procedure that requires extra-corporeal circulation. In this procedure the atrium is cut and sewn again to compartmentalize the atrium en therefore prevent the atrium maintaining atrial fibrillation. In recent years a less invasive procedure has developed to treat atrial fibrillation. This minimal invasive surgery is performed through thoractomy or thoracoscopy and is performed on a beating heart. A pulmonary vein isolation is performed with a clamp and if patients have persistent atrial fibrillation additional left atrial lesions are made on the atrium to compartmentalize the atrium. Finally the left atrial appendage is removed to reduce the occurrence of stroke. This procedure has a success rate of 68% after one year. Recently hybrid surgical procedures have been described that combine the minimal invasive thoracoscopic surgery with (epicardial or endocardial) elektrophysiological measurement. Patients with a large left atrium (diameter>45mm) or a failed catheter ablation are eligible for AF surgery. | *** <b>Surgical treatment:</b> Surgery is a more invasive, but effective modality to treat atrial fibrillation. The classical cut and sew Maze procedure is a open chest procedure that requires extra-corporeal circulation. In this procedure the atrium is cut and sewn again to compartmentalize the atrium en therefore prevent the atrium maintaining atrial fibrillation. In recent years a less invasive procedure has developed to treat atrial fibrillation. This minimal invasive surgery is performed through thoractomy or thoracoscopy and is performed on a beating heart. A pulmonary vein isolation is performed with a clamp and if patients have persistent atrial fibrillation additional left atrial lesions are made on the atrium to compartmentalize the atrium. Finally the left atrial appendage is removed to reduce the occurrence of stroke. This procedure has a success rate of 68% after one year. Recently hybrid surgical procedures have been described that combine the minimal invasive thoracoscopic surgery with (epicardial or endocardial) elektrophysiological measurement. Patients with a large left atrium (diameter>45mm) or a failed catheter ablation are eligible for AF surgery. | ||
Studies have shown no benefit of rhyhtm control over rate control, thus the selection of strategy is mainly dependent of patient and atrial fibrillation characteristics. This means that, since rate control is easier to achieve, rate control should be the initial strategy in all patients, especially in old patient and patients with no or few symptoms of atrial fibrillation. The target heart rate to achieve in rest is <110 beats per minute. In patients with persistent complaints of atrial fibrillation rhythm control can be initiated on top of rate control. Young patients with paroxysmal atrial fibrillation and no underlying heart disease might benefit from early (invasive) rhythm control to halt progression of the disease. However, independent of the treatment strategy, proper anti-coagulation is important and necessary in patients with risk factors.<Cite>Camm2012,Camm2010</Cite> | Studies have shown no benefit of rhyhtm control over rate control, thus the selection of strategy is mainly dependent of patient and atrial fibrillation characteristics. This means that, since rate control is easier to achieve, rate control should be the initial strategy in all patients, especially in old patient and patients with no or few symptoms of atrial fibrillation. The target heart rate to achieve in rest is <110 beats per minute. In patients with persistent complaints of atrial fibrillation rhythm control can be initiated on top of rate control. Young patients with paroxysmal atrial fibrillation and no underlying heart disease might benefit from early (invasive) rhythm control to halt progression of the disease. However, independent of the treatment strategy, proper anti-coagulation is important and necessary in patients with risk factors.<Cite>Camm2012,Camm2010</Cite> | ||
* '''Anticoagluation treatment:''' Proper anti-coagulation is important in patients with atrial fibrillation to reduce the occurrence of stroke. In patient with atrial fibrillation the indication of anti-coagulation is based on certain risk-factors a patients has. A score is created to facilitate this decision making. The CHADS<sub>2</sub>VASc2 score incorporates these risk factors. A patient has no indication for anti-coagulation if there is a low-risk of thromoembolic complications. These patients are defined as males or females <65 years old with no other risk factors. This translates is a CHADSVASc score of 0, or a CHADSVASc score of 1, where 1 point is based on the female sex. In all other cases anti-coagulation with coumarins or other new anticoagulation drugs (dabigatran, rivaroxiban, apixaban) is indicated if no strong bleeding-risk exist. | * '''Anticoagluation treatment:''' Proper anti-coagulation is important in patients with atrial fibrillation to reduce the occurrence of stroke. In patient with atrial fibrillation the indication of anti-coagulation is based on certain risk-factors a patients has. A score is created to facilitate this decision making. The CHADS<sub>2</sub>VASc2 score incorporates these risk factors. A patient has no indication for anti-coagulation if there is a low-risk of thromoembolic complications. These patients are defined as males or females <65 years old with no other risk factors. This translates is a CHADSVASc score of 0, or a CHADSVASc score of 1, where 1 point is based on the female sex. In all other cases anti-coagulation with coumarins or other new anticoagulation drugs (dabigatran, rivaroxiban, apixaban) is indicated if no strong bleeding-risk exist. It is important to note that anti-coagulation is independent of the underlying rhythm. | ||
==AV node arrhythmias== | ==AV node arrhythmias== | ||