Heterogeneity Of AF
Not all AF are the same!!!!!!
Dr.Mervat Aboulmaaty
Prof. of cardiology
Ain Shams university
2008
Heterogeneity Of AF
Not all AF are the same!!!!!!
Heterogeneity Of AF
Not all AF are the same!!!!!!
AF with fast vent response &
aberrancy
AF with controlled vent. response
AF WITH LBBB
AF with IVCD
AF regular because of VT
Atrial Flutter/AF
AF and AT Flutter
AF WITH SLOW VR
AF with CHB
AF with WPW syndrome
AF with WPW syndrome
AF degenerating to VF
AF in Patient with CHF and CRT
AT Flutter and 1:1 conduction
After CV A-Pacing Native
Conduction
AF Heterogeneity
Prevalence

AF prevalence doubling with each decade
◦ 0.55 at age 50-59 years
◦ 9% at age 80-89 years
3-fold increase in men
 New onset AF: men are 1. 5 times as
likely as women to develop it

Incidence of AF in Men and Women
Associated conditions with AF
Reversible Causes of Atrial Fibrillation
 alcohol intake (“holiday heart syndrome”),
surgery, electrocution,
 MI, pericarditis, myocarditis,
 PE, pulmonary diseases,
 hyperthyroidism
 with Atrial flutter, WPW,AVNRT, AVRT
 complication of cardiac or thoracic
surgery

Associated conditions with AF
Acute and chronic coronary disease
 HTN
 Hypertrophic ,dilated & restrictive CM
 ASD
 Valvular
Rheumatic 40% MS
75% MR

Cardiac conditions increasing the
risk of AF
Men
Women
20%
31%
HF
4.5%
5.9%
Valve disease
1.8%
3.4 %
Myocardial infarction
40%
20%
Atrial Fibrillation Without Associated
Heart Disease
lone AF
Lone AF before age 60 yrs without HTN or overt
structural HD (clinical exam, ECG and echo)
 30% to 45% of paroxysmal AF and
20% to 25% of persistent AF occur in younger
patients without underlying disease
 AF can present as an isolated or familial
arrhythmia
 In elderly,

◦ myocardial stiffness may be associated with AF,
◦ Heart disease may be coincidental and unrelated to
AF.
AF and autonomic influence
Vagal predominance in the minutes
preceding the onset of AF
 Vagally mediated AF occurs at night or after
meals
 Cholinergic agents such as disopyramide are
helpful to prevent recurrent vagally
mediated AF
 Adrenergically induced AF occurs during
daytime in pts with organic HD
 Beta blockers for adrenergically induced AF

Autosomal dominant hereditary AF
Mapping analysis of the AF family
ECG and missense mutation
DNA and amino acid sequence of KCNQ1 missense mutation associated
with affected members in the AF family. DNA sequence analysis revealed an
A to G substitution causing an S140G mutation in the S1 segment of
KCNQ1.
AF family with an autosomal
recessive inheritance pattern
AF in the family manifests with early onset
at fetal stage and is associated with neonatal
sudden death
 Some cases ventricular tachyarrhythmias and
cardiomyopathy.
 Heterozygous carriers have significant
prolongation of P-wave duration compared
with non-carriers
 The maximum multipoint LOD score of 4.10
was obtained for 4 markers: D5S426,
D5S493, D5S455, and D5S1998.

Circulation. 2004;110:3753-3759
Genetic map with chromosome 5p13 markers and location
of putative arAF1 gene
Patterns of AF
Mechanisms of AF
Rapidly firing atr automatic
foci PV triggers
Anatomical substrate for
reentry within the PV
Symptoms of AF




Embolic complication
Exacerbation of HF
Palpitations, chest pain, dyspnea, fatigue,
lightheadedness
Syncope.
◦ upon conversion in patients with SSS
◦ rapid ventricular rates in patients with HCM, AS,
WPW


Polyuria with the release of ANP as
episodes of AF begin or terminate.
Tachycardia-mediated cardiomyopathy
Pharmacological and non
pharmacological Treatment






Drugs and ablation are effective for both rate and
rhythm control
Ryhtm control vs Rate control
For rhythm control, drugs are typically the first
choice and LA ablation is a second-line choice (
symptomatic lone AF young pts , no structrual
HD)
RF ablation for WPW, AVRT, Atrial Flutter
RF ablation in association with cardiac surgery
face a unique opportunity during MV
Replacement, LAA obliteration
Standalone Surgical procedure (maze III or LA
ablation)
Circumferential Pulmonary-Vein Ablation
RF Pulmonary Vein Isolation
Oral, H. et al. N Engl J Med 2006;354:934-941
Pharmacological and NonPharmacological Treatment
“Ablate and pace” strategy that often yields
remarkable symptomatic relief
( the
negative effect of long-term RV) BIV Pacing
 Atrial pacing, either in RA alone or Biatrial
to prevent recurrent paroxysmal AF in pts
with Bradycardic indication for Pacing (SSS
AAI vs VVI)
 Atrial pacing IS Not a primary therapy for
prevention of AF
 Atrial defibrillators for patients with LV
dysfunction who are candidates
for implantable ventricular defibrillators

Mortality and Morbidity with AF
Death
 AF Increases Mortality with AMI
 AF Increases mortality 50% Men 90% Women
 Highest death 1st yr after AF diagnosis
Stroke
 Risk 35%
 1.5% at age 50-59 y
 23.5% at age 80-89
 AF+HF+CAD increase risk of a stroke 2 fold
Risk of Stroke

CHADS2 Risk Criteria Score
◦
◦
◦
◦
◦
Prior stroke or TIA
Age 75 y
Hypertension
Diabetes mellitus
Heart failure
2
1
1
1
I
aspirin (325 mg) associated with 44% stroke
rate reduction
 Warfarin 50% more effective than aspirin for
prevention of ischemic stroke

‫‪Thank you‬‬
‫السالم عليكم‬
AF in Patient with CHF and CRT
General schema representing AF
mechanisms
Predictors of AF


HTN and DM were significant
independent predictors of AF increasing
the risk 1.5 fold. (Framingham Study)
HTN is responsible for more AF (14%) than
any other risk factor
Predictors of AF

Independent ECHO predictors of AF :
◦ LA enlargement,
◦ LV fractional short.
◦ LV wall thickness

( 5mm
( 5%
( 4mm
AF 39%)
AF 34%)
AF 24%)
ECG evidence of:
◦ LVH was also a powerful age adjusted
predictor
Mortality results
Cumulative mortality
(%)
Rhythm control
Rate control
25
20
15
10
5
0
Year 1
Year 2
Year 3
Year 4
Year 5
N Engl J Med 2002;347:1825-33.