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Tachycardia: Difference between revisions
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====Management:==== | ====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> | ||
* <B>Rate control:</b> In atrial fibrillation the ventricle can have a fast irregular rate that can | * <B>Rate control:</b> In atrial fibrillation the ventricle can have a fast irregular rate that can lead to complaints of palpitations and a tachycardiomyopathy. One of the strategies in managing atrial fibrillation is to control ventricular rate <110bpm. In patients with persistent complaints or with heart failure a resting heart rate of <80 is advised. In this strategy no attempt is made to achieve sinus rhythm. This is the only treatment option in patients with permanent atrial fibrillation. Due to the fast irregular ventricular rate a dilated tachycardiomyopathy can develop and proper rate control can revert these ventricular changes. Rate control can be achieved with beta-blockers, non-dihydropyridine Ca-antagonists and digoxine. | ||
** <b>Invasive treatment:</b> | ** <b>Invasive treatment:</b> | ||
*** <b>His-Ablation with pacemaker implantation: </b>Patients with accepted atrial fibrillation and complaints of a fast irregular ventricular frequency who do not tolerate medication can be helped with a targeted His bundle ablation with catheter ablation to induce complete AV-block. A implanted pacemaker can take over the ventricular firing frequency independent of the atrium. | *** <b>His-Ablation with pacemaker implantation: </b>Patients with accepted atrial fibrillation and complaints of a fast irregular ventricular frequency who do not tolerate medication can be helped with a targeted His bundle ablation with catheter ablation to induce complete AV-block. A implanted pacemaker can take over the ventricular firing frequency independent of the atrium. A pacemaker might be indicated if rate control leads to a iatrogenic bradycardia. | ||
* <b>Rhythm control:</b> In rhythm control all efforts are made to achieve and maintain sinus rhythm. This can be done with anti-arrhythmic drugs. Most effective are the Class IC and III anti-arrhythmic drugs. Overall rhythm control is difficult and anti-arrhythmic drugs have | * <b>Rhythm control:</b> In rhythm control all efforts are made to achieve and maintain sinus rhythm. This can be done with anti-arrhythmic drugs. Most effective are the Class IC and III anti-arrhythmic drugs. Overall rhythm control is difficult and anti-arrhythmic drugs might have (pro-arrhythmic) side effects, if patients have contra-indications. Therefore prescription of these drugs should occur with caution. | ||
** <b>Invasive treatment:</b><cite>Calkins</cite> | ** <b>Invasive treatment:</b><cite>Calkins</cite> | ||
*** <b>Catheter ablation:</b> Medical therapy is not always sufficient to maintain sinus rhythm. In the last decade of 20th century it was discovered that atrial fibrillation is triggered from the pulmonary veins and that selective ablation of these trigger sites can reduce atrial fibrillation recurrence. As this technique evolved it is now common to ablate an area around the pulmonary veins to isolate them from the atrial tissue. The left atrium is approached through the inter-atrial septum and with the use of imaging and electrocardiographic signals a 3D map is made to navigate the atria. The pulmonary vein isolation can be performed with multiple energy sources. This is a difficult and long procedure, that depending on the technique used has (severe) complications. The success rate of the procedure varies on the experience of the operator (40-60%). Often the success rate can be increased by performing multiple procedures. | *** <b>Catheter ablation:</b> Medical therapy is not always sufficient to maintain sinus rhythm. In the last decade of 20th century it was discovered that atrial fibrillation is triggered from the pulmonary veins and that selective ablation of these trigger sites can reduce atrial fibrillation recurrence. As this technique evolved it is now common to ablate an area around the pulmonary veins to isolate them from the atrial tissue. The left atrium is approached through the inter-atrial septum and with the use of imaging and electrocardiographic signals a 3D map is made to navigate the atria. The pulmonary vein isolation can be performed with multiple energy sources. This is a difficult and long procedure, that depending on the technique used has (severe) complications. The success rate of the procedure varies on the experience of the operator (40-60%). Often the success rate can be increased by performing multiple procedures. | ||