AF & ANTI-COAGULATION

ATRIAL FIBRILLATION
Definition
Disorganised atrial depolarisation propagating in different directions without effective atrial contraction
Atrial fib 350-600 beats /min.
ventricular response is grossly irregular at 100-160 beats

Types

Management

CLASS 1

AF

Sodium channel blockers

Mechanism of Action

Slows Phase 0 depolarisation

Shortens phase 3
repolarisation
Slows phase 3; Flecanide,
Propafenone

Adverse effects

Indications

heart failure and

hypotension

Interaction/CI

AF & ANTI-COAGULATION

CLASS 2

Anti-sympathetic drugs/ BAdrenoreceptor Blocker

Atenolol, metoprolol,
carvedilol

Inhibits phase 4 depolarisation

in SA and AV nodes

CLASS 3

Calcium channel blockers

Diltiazem or verapamil

OTHERS

K channel blockers
Amiodarone (IV
loading dose)

CLASS 4

Acute
Bronchospasm B2
antagonism (Caution in
asthma)
Negative inotropism
Negative
chronotropism
Chronic
Fatigue
Peripheral vasculature

Inhibit Phase III repolarisation

Prolong phase 3 repolarisation
in ventricular muscle fibers

Photosensitivity
Thyroid dysfunction
Pulmonary fibrosis
Many others

Inhibit Ca - dependent
depolarisation
Inhibits action potential in SA
and AV nodes.

Headache
Constipation
Ankle oedema
Hypotension

Cardiac glycosides
Vagolytic

Adenosine
Antipurinergic

Magnesium sulphate

SUMMARY
Acute pharmacological cardioversion
o Class 1C Flecanide or III - K channel blockers Amiodarone
Rhythm control
o Standard BB

Supraventricular
arrhythmias, Angina,
Hypertension, Prophylaxis of
cluster headache

AF & ANTI-COAGULATION
o Class 1C or III
Rate control B, C, D
o BB, CCB, Digoxin
Stroke risk reduction
o Antiplatelet or anticoagulant

Anti-coagulation
Stroke risk with AF

THROMBIN I.

A.PLATELETS

A.COAGULATION
ASPIRIN

Mechanism of action
Inhibits TA2 synthesis from arachidonic acid in platelets by
preventing arachidonate from binding to the active site.
Inhibition of COX-1.
Irreversibly inhibit the binding of ADP to its receptors on
platelets and thereby the action of GP IIb/IIa receptors
required for platelets to bind to fibrinogen and to each
other.

Indication
Prophylaxis of TIA

Method used
Should be taken 30 min before
ibuprofen or 8h after ibuprofen.
50 to 325mg oral.

Prophylaxis of thrombotic event in ACS

To prevent thrombotic event in asso with PCI

Oral
Metabolise by CYP450

ENOXAPARIN

Interfere with formation of thrombi. It binds to antithrombin

III (AT3), with the rapid inactivation of coagulation factors.
Fasten the interaction of AT3 with thrombin and Factor Xa

Prevent venous thrombosis in PE and acute MI.

Prophylaxis to prevent post-op VT and those
in acute stage of MI. Used in extracorporeal
devices (dialysis machine)

Injectable. Parenteral
Safe for pregnant

DABIGATRAN

Direct thrombin inhibitor

Prevent stroke and systemic embolism

CLOPIDOGREL

HEPARIN

Mechanism of action

Indication

Method used

Does not require INR monitoring.

Has few drugs interaction
compared to warfarin.
Interaction

AF & ANTI-COAGULATION
WARFARIN
Reduced vitamin K is an essential co-factor for
the synthesis of the clotting factors II, VII, IX
and X. Reduced vitamin K is achieved by the
actions of vitamin K reductase on vitamin K.
Warfarin antagonise the actions of Vitamin
K reductase on Vitamin K. This underlies the
therapeutic role of Vitamin K in the reversal of
the effects of Warfarin in cases of overanticoagulation.

Prevent the progression or

recurrence of acute DVT or PE
after initial heparin treatment.
Prevent venous
thromboembolism during
orthopaedic or gynaecologic
surgery.

Oral coagulants
INR was adopted to monitor
[warfarin] keep between 2 to 3
DO NOT give to PREGNANT pt.
Teratogenic; could cause
abortion and birth defects.

Inducers
Carbamazepine
Rifampicin
Alcohol chronic
St Johns Wort
Inhibitors x de metaboliser
Amiodarone
Erythromycin
Simvastatin
Ciprofloxacin
Grapefruit juice
Phenytoin