Epidemiology
- xxx
Etiology
- Ruptured Sinus of Valsalva Aneurysm (see [[Sinus of Valsalva Aneurysm]])
Presentations
- xxx
Clinical
(may be asymptomatic)
- Hypotension (see [[Hypotension]]): particularly with rapid ventricular response
- Palpitations
- Chest Pain
New-Onset Atial Fibrillation in Sepsis
- Epidemiology: 6-20% of patients with severe sepsis develop new-onset AF
- Clinical
- Patients with new-onset AF and severe sepsis are at a 4-fold increased risk of in-hospital CVA and a 7% increased risk of death, as compared with patients with no AF and patients with preexisting AF
- Possible Mechanisms for Increased Risk of CVA in New-Onset AF in Severe Sepsis: new-onset AF might just be a marker for the sickest patients with greatest inherent CVA risk, sepsis itself might result in an increased risk for CVA (by hemodynamic collapse, coagulopathy, or systemic inflammation), or new-onset AF might be a source of cardio-embolic CVA
- Patients with severe sepsis had a 6-fold increased risk of in-hospital CVA, as compared with hospitalized patients without severe sepsis
- Patients with severe sepsis and preexisting AF did not have an increased CVA risk, as compared with patients without AF
[Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis JAMA 2011;306(20):doi:10.1001/jama.2011.1615]
- Patients with new-onset AF and severe sepsis are at a 4-fold increased risk of in-hospital CVA and a 7% increased risk of death, as compared with patients with no AF and patients with preexisting AF
Treatment
Rate Control Agents
- Digoxin
- Calcium Channel Blockers with AV Nodal Blocking Activity: diltiazem, verapamil
- Beta Blockers: metoprolol, atenolol, etc
Anticoagulation
- ACCP recommends ASA for pts 60-75 y/o (if no risk factors)
- ACCP recommends coumadin (INR 2-3) for pts >60 y/o with heart disease or diabetes and in all pts >75 y/o
- Dabigatran (Pradaxa) (See [[Dabigatran]])
Cardioversion
- AF <48 hrs: synchronized conversion (120-200 J) without anticoagulation
- AF >48 hrs: anticoagulation x 2 wks, then conversion (if TEE shows no clots, conversion is safe without anticoagulation).
- Risk Factors for Recurrent AF After Conversion: age and gender are not risk factors for recurrence
- EF <40%
- LA >3.9 cm (long axis)
- Pharmacologic Cardioversion
- Dronedarone: significantly reduces the risk for hospitalization due to cardiovascular events or death in patients with paroxysmal or persistent AF or flutter
- Decreases death rate from cardiac arrhythmia
- Side Effects: increased creatinine, without change in renal function (due to partial inhibition of tubular organic cation transporters), low incidence of thyroid and pulmonary toxicity
- Dronedarone: significantly reduces the risk for hospitalization due to cardiovascular events or death in patients with paroxysmal or persistent AF or flutter
Treatment of Concomitant OSA (if present)
- Use of CPAP (>4 hrs/nt) in OSA patients with AF has been shown to decrease risk of recurrent AF after cardioversion (42% recurrence rate vs. 82% recurrence rate):
- May be related to effects of OSA on nocturnal hypoxemia, hypercapnia, sympathetic drive, and changes in intrathoracic pressure
References
- Hohnloser SH, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009;360:668-678
- Zareba KM. Dronedarone: a new antiarrhythmic agent. Drugs Today 2006;42:75-86
- Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis JAMA 2011;306(20):doi:10.1001/jama.2011.1615