ef lucrri dr.

Viviana AURSULESEI
FIBRILAIA ATRIAL: DE CE?

Cea mai frecvent tulburare de ritm

FIBRILAIA ATRIAL: DE CE?

Incidena crete n timp dar i cu vrsta

Prevalen dubl > 50 ani
FIBRILAIA ATRIAL: DE CE?

Asociat cu morbiditate crescut: risc estimat AVC x 5

FIBRILAIA ATRIAL: DE CE?
X2

10-40%

30%

ESC Guidelines 2016 on the Management of Atrial Fibrillation

FIBRILAIA ATRIAL I CREIERUL: dincolo
de AVC

Studii clinice
Adult Changes in Thought
Study
OnTarget, Transcend
Mecanisme
via AVC ischemic
Embolii silenioase
Hipoperfuzie cerebral
Inflamaie
Disfuncie microvascular
FIBRILAIA ATRIAL: DE CE?
Asociat cu morbiditate crescut

Predictor independent de mortalitate

Spitalizare prelungit, dependen funcional prin consecine
ESC Guidelines 2016 on the Management of Atrial Fibrillation
FIBRILAIA ATRIAL ESTE O CONDIIE FRECVENT SILENIOAS CU
30%
CONSECINE SERIOASE APARIIA AVC
FIBRILAIA ATRIAL ESTE O CONDIIE FRECVENT SILENIOAS CU
30%
CONSECINE SERIOASE APARIIA AVC
TEHNICI NOI DE DEPISTARE FIA n AVC/AIT CRIPTOGENETIC

Monitorizare Holter ecg optim 72 ore

Randament diagnostic +36%
TEHNICI NOI DE DEPISTARE FIA n AVC/AIT CRIPTOGENETIC

Monitorizare continu loop recorder implantat

FIBRILAIA ATRIAL: ce factori de risc?

20%

30-40%

30% 25%

20%

10-15%
FIBRILAIA ATRIAL: ce mecanisme?

Factori Predispoziie
Factori atriali
electrofiziologici genetic
REMODELARE
ANATOMC I MECANISM FOCAL SDR. CARDIACE
ELECTRIC IPOTEZA MOTENITE
MULTIPLE WAVELET"
FIBRILAIA ATRIAL: consecine
Conducere atrio-ventricular

Modificri hemodinamice

Tromboembolism
ELEMENTE CHEIE: detecie i evaluare
Case
detection

Assessment EKG +
Anamneza
OR
Examen fizic
Rate- Rhythm- Referral
Ecocardiografie
control control

Follow-up

Follow-up
Algoritm diagnostic: ntrebri cheie?
CARACTERIZAREA FIBRILAIEI ATRIALE

ETIOLOGIE

SIMPTOME

VECHIME

ESC Guidelines 2016 on the management of Atrial Fibrillation

I. CONDIII PREDISPOZANTE SAU CARE MENIN
FIBRILAIA ATRIAL

1. Afeciuni cardiace structurale valvulare i

non-valvulare/electrice (canalopatii, CM)
2. Afeciuni extracardiace
3. Consum alcool, stres, efort intens
4. Postoperator, tulburri electrolitice
5. Istoric familial

FIBRILAIA ATRIAL IDIOPATIC ("lone AF")

European Heart Journal, 2016
II. FIBRILAIA ATRIAL: SIMPTOMATIC?
SCORUL EHRA

ESC Guidelines 20106 on the management of Atrial Fibrillation

III. Vechimea fibrilaiei atriale

Maxim 7 zile

ESC Guidelines 2010 on the management of Atrial Fibrillation

FIBRILAIA ATRIAL: CUM TRATM?
FIBRILAIA ATRIAL: PAI MANAGEMENT

Etiology

ESC Guidelines 2010 on the management of Atrial Fibrillation

 FIBRILAIA ATRIAL

CONVERSIE N RS SCDERE FRECVEN

VENTRICULAR
CARDIOVERSIE
70/min repaus
ELECTRIC FARMACOLOGIC 90/min efort
(iniial < 110/min)
 CARDIOVERSIA
ELECTRIC

Circuit de sincronizare prin care se

emite ocul electric la 30 milisecunde
dup debutul complexului QRS

Cnd?
n urgen (afectare
hemodinamic)
Electiv
FIBRILAIA ATRIAL

VECHIME
ETIOLOGIE boal structural cardiac sau nu
SIMPTOME cum este tolerat
TROMBOZ INTRACAVITAR AS/urechiu
 I. CONTROLUL FRECVENEI VENTRICULARE SAU A
RITMULUI: VECHIMEA FA?

CARDIOVERSIE FARMACOLOGIC CARDIOVERSIE ELECTRIC

ESC Guidelines 2010 on the management of Atrial Fibrillation

II. CONTROLUL FRECVENEI VENTRICULARE
SAU A RITMULUI: ETIOLOGIE, SIMPTOME?
CONTROL RITM
PACIENT TNR, ACTIV, SIMPTOMATIC
BOAL STRUCTURAL CARDIAC
CARDIOVERSIE ABSENT/MINIM
FA PAROXISTIC/PERSISTENT MRIME ATRII, ABSENA TROMBI

CONTROL FRECVEN REFUZ PACIENT /EEC

VENTRICULAR CARDIOVERSIE
PACIENT VRSTNIC?
FA PERMANENT CONTRAINDICAII
POATE FI I O SITUAIE CARDIOVERSIE - CAUZE
TEMPORAR!! NECORECTATE /CORECTABILE

ESC Guidelines 2010 on the management of Atrial Fibrillation

CONTRAINDICAII CARDIOVERSIE ELECTRIC

cauza toxic alcoolic (sevraj 3 luni)

insuficien cardiac cu cardiomegalie important
miopericardite acute
afeciuni tiroidiene netratate
valvulopatii mitrale sau pericardit constrictiv cu indicaie operatorie
boal de nod sinusal (risc de asistol)
accidente embolice recente (se temporizeaz 3 luni cu anticoagulare)
tromboz intracavitar - necesar ETE precardioversie
hipokaliemie
hipoxemie sever (BPOC, CPC)
pacient digitalizat
 CONTROLUL RITMULUI N FA:
CARDIOVERSIA FARMACOLOGIC
 CONTROLUL RITMULUI N FA:
CARDIOVERSIA FARMACOLOGIC

BOAL CARDIAC STRUCTURAL PREZENT

ESC Guidelines 2010 on the management of Atrial Fibrillation

CONTROLUL RITMULUI cu VERNAKALANT

Recomandat n FIA fr boal structural

cardiac/minim

ESC Guidelines 2016 on the management of Atrial Fibrillation

POSTCARDIOVERSIE prevenia
recurenelor

CE ATITUDINE PENTRU MENINEREA

RITMULUI SINUSAL?

PROFILAXIE
ANTIARITMIC
 PRINCIPII DE TERAPIE ANTIARITMIC pentru
MENINEREA RITMULUI SINUSAL (I)
REALITATEA PRACTIC VERSUS INDICAII
1. Tratamentul este motivat pentru a reduce simptomele i recurena FA
2. Terapia antiaritmic de succes mai degrab reduce dect elimin
recurenele FA
3. Dac un drog antiaritmic eueaz, se poate alege un alt drog
4. Proaritmiile induse de droguri/efectele extracardiace sunt frecvente
5. Alegerea de prim intenie a unui drog antiaritmic trebuie ghidat de
sigurana administrrii i apoi de eficien!
6. La pacienii cu risc crescut de efecte adverse profilaxia antiaritimic
poate fi administrat pe termen scurt (4 sptmni)

ESC Guidelines 2010 on the management of Atrial Fibrillation

PRINCIPII DE TERAPIE ANTIARITMIC pentru
MENINEREA RITMULUI SINUSAL (II)

ESC Guidelines 20106 on the management of Atrial Fibrillation

DRONEDARONE N FIBRILAIA ATRIAL
AMIODARONA: ce alte efecte adverse?
CONTROLUL RITMULUI POSTCARDIOVERSIE:
ce alte droguri?

ESC Guidelines 2016 on the management of Atrial Fibrillation

CE ALTE OPIUNI N CAZ DE RECUREN?
ABLAIE PE CATETER

ESC Guidelines 2016 on the management of Atrial Fibrillation

ABLAIA PE CATETER: atitudine practic

Da, numai dac:

FA paroxistic, persistent
exist recuren dup antiaritmice (scheme seriate)
antiaritmice C.I. /prost tolerate
acceptat de pacient

Este opiunea de preferat la tnr vs amiodaron

ABLAIA PE CATETER

STADIUL TIP FA
AFECTRII ISTORICUL FA
MRIME ATRIU STNG
ATRIALE
BOAL
PREZENT
STRUCTURAL ABSENT
CARDIAC

OPIUNI MEDICAIE ANTIARITMIC

CONTROLUL FC
ALTERNATIVE ALEGEREA PACIENTULUI

ESC Guidelines 2016 on the management of Atrial Fibrillation

ABLAIA PE CATETER
microcircuits
of reentry

critical fibres

focal triggers
ABLAIA PE CATETER
ABLAIE CHIRURGICAL
Clasic procedeul labirint (Cox maze biatrial cut
and sew)
Izolare AS posterior + leziune ctre inel mitral posterior

Leziune cavo-tricuspid
Leziuune cavo-cav
ndeprtare urechiu AS
ABLAIE CHIRURGICAL
Minim invaziv (toracosopic) recuren dup
ablaie pe cateter radioablaie, criotermie epicardic

Tehnici hibrid ablaie endo + epicardic

 TEHNICI HIBRID
Chirurgical minim invaziv (toracosopic) abalaie
epicardic
Pe cateter endoablaie
FIBRILAIA ATRIAL: PAI MANAGEMENT

Etiology

ESC Guidelines 2010 on the management of Atrial Fibrillation

INDICAIA DE TROMBOPROFILAXIE: CUM?
Stratificare risc AVC
SCOR CHA2DS2-VASc

*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary
cohorts may vary from these estimates.
ESC Guidelines 2016 on the management of Atrial Fibrillation
 CONDUITA TROMBOPROFILACTIC:
ntre beneficiu i risc
Scorul de risc HAS-BLED

SCOR 3 = RISC NALT DE SNGERARE

TROMBOPROFILAXIE: CUM?

Dabigatran
Apixaban
Rivaroxaban
ESC Guidelines 2016 on the management of Atrial Fibrillation
TROMBOPROFILAXIE PRECARDIOVERSIE

Anticoagulare 3 sptmni dac FIA > 48 ore

Excepie! ETE nainte de cardioversie

ESC Guidelines 2016 on the management of Atrial Fibrillation

TROMBOPROFILAXIA POSTCARDIOVERSIE
Stratificare risc tromboembolic

CHA2DS2-VASc =/>2 anticoagulare de lung

durat
CHA2DS2-VASc < 2 antifoagulare 4 sptmni

ESC Guidelines 2010 on the management of Atrial Fibrillation

FIBRILAIA ATRAL
CE DROGURI?
ALEGEREA DROGULUI
FIBRILAIA ATRIAL
Stroke Prevention in Atrial Fibrillation
Limitations of Anticoagulation Therapy in Atrial Fibrillation

Unpredictable Slow onset/offset

response of action

Anticoagulation
Narrow therapeutic
window
therapy has Numerous food-drug
interactions
(INR range 2-3) several
limitations that
Routine coagulation make it difficult Numerous drug-drug
interactions
monitoring to use in
practice
Frequent dose Risk of Bleeding
adjustments Complications

OAC was #1 in 2003 and 2004 in the number of mentions of deaths for
drugs causing adverse effects in therapeutic use
OAC caused 6% of the 702,000 ADEs treated in the ED/year; 17% required
hospitalization
J Thromb Thrombolysis 2008; 25: 52-60
 New antithrombotic treatments in Phase III trials
for stroke prevention in atrial fibrillation

Tissue Factor Collagen

Aspirin
Apixaban Plasma Clotting
Rivaroxaban ADP
Cascade
Edoxaban Thromboxane A2 Clopidogrel
Prasugrel
Prothrombin AZD6140
Idraparinux AT Factor Conformational
Xa Activation of GPIIb/IIIa

Thrombin Platelet Aggregation

Dabigatran
Ximelagatran
Fibrinogen Fibrin

Thrombus
ANTICOAGULANTE ORALE NOI

Rivaroxaban

Nu sunt inferioare n prevenia Dabigatran

AVC/embolii n FA
Risc mai mic de hemoragii fatale,
inclusiv intracerebrale
Risc crescut de HDS, cu excepia Apixaban
Nu necesit monitorizarea coagulrii
ANTICOAGULANTE ORALE NOI
Features Warfarin New agents

Onset Slow Rapid

Dosing Variable Fixed

Food/drug interactions Many None or very few

Monitoring Yes No

Half life Long Short

Antidote Yes No
NCHIDERE URECHIU AS
NCHIDERE URECHIU AS