AF9th October 2013

Dr Julian Tomkinson

IntroductionNICE Guidance 2006

“Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and if left untreated is a significant risk

factor for stroke and other morbidities”

Why is AF Important?• AF prevalence rate in primary care is 1.2%

600,000 in England alone• Atrial fibrillation predisposes patients to stroke, increasing

stroke risk by 500-700%• 12,500 strokes per year (of the 150,000 total) attributable

to AF• – 4,300 deaths in hospital• – 3,200 discharges to residential care• – 8,500 deaths within the first year

DH Figures 2007

Consequences

Loss of active ventricular filling :

• Stagnation of blood in the atria leading to thrombus formation and a risk of embolism, increasing the risk of stroke.

• Reduction in cardiac output (especially during exercise) which may lead to heart failure.

Type of AF

• Paroxysmal (subsides within 48 hours)

• Persistent ( >7days)

• Permanent (> 1 year)

Aetiology• Idiopathic ('lone') atrial fibrillation

(AF): 5-10% of patients (diagnosis of exclusion with no evidence of any specific underlying cause).

• Hypertension (especially with associated left ventricular hypertrophy).

• Coronary artery disease.• Valvular heart disease, especially

mitral valve stenosis.• Cardiac surgery.• Myocarditis.• Atrial septal defect.• Atrial myxoma.• Sick sinus syndrome.

• Pre-excitation syndromes, eg WPW• Dilated and hypertrophic

cardiomyopathy.• Pericardial disease, eg pericardial

effusion, constrictive pericarditis.• Hyperthyroidism.• Acute infections (especially

pneumonia in the elderly).• Acute excess alcohol intake or chronic

excess alcohol intake.• Respiratory (lung cancer, COPD,

pleural effusion, PE, pulmonary hypertension).

• Obesity, sleep apnoea, haemochromatosis, sarcoidosis, and narcotic abuse

• Genetic: autosomal dominant

Detection• Breathlessness• Palpitations• Syncope/dizziness• Chest discomfort• Stroke/TIA

manual pulse palpation should be performed to assess for the presence of an irregular pulse that

may indicate underlying AF

Detection

Opportunistic20% asymptomatic

Patients Attend for Many Reasons

• Medication reviews• Chronic Illness monitoring• Flu vaccination• Just for a chat

OPPORTUNITY TO CHECK PULSE

Making the Diagnosis

ECG

Benefits

• Symptom Control• Reduce Strokes, mortality, morbidity• Reduce Cost to patients, families,

social care, PCTs, NHS…………..

150,000 strokes per year in the UK

• 410 per day• 17 per hour• Within the next four hours, 10 patients with AF will have suffered a stroke• 8 would have been known to be high risk of stroke• 6 should have been on warfarin• 3 will go home • 5 will end up in residential care • 2 will die....

The Stroke Association: www.stroke.org.uk.

Scenario 1Mrs April Fillingham 75 years old

Attends for Flu Jab

You take her pulse and it is irregularly irregular with rate 84

WHAT DO YOU DO NEXT?

Scenario 1 (continued)

• Mrs F says she feels well generally• Past history of COPD• She gets breathless running upstairs but put

this down to COPD & age• No chest pain

Scenario 1 (continued)

Mrs F attends for ECG and bloods

• ECG shows AF rate 92• BP 136/87• FBC U+E’s TFTs glucose all ok• INR 1

Risk factors Mrs AF

• No murmurs• No recent acute chest infections• Minimal alcohol intake• No signs of heart failure

Scenario 1 (continued)

What do you do now?

Explanation

How do you explain to a patient they have AF?

Explanation“Atrial fibrillation (AF for short) is a condition that

affects the heart, causing an irregular pulse. It occurs when the electrical impulses controlling the heartbeat become disorganised, so that the heart beats irregularly and too fast. When this

happens, the heart cannot efficiently pump blood around the body”

NICE guide for patients

http://www.youtube.com/watch?v=wqau2_FQq1E

Useful resource

RCGPCase Cards

Management

Confirmed diagnosis of AF

Further investigations and clinical assessment including risk stratification for stroke/thromboembolism

Paroxysmal AF Persistent AF Permanent AF

Rhythm-control Rate-control Remains symptomatic

Failure of rhythm-control

OR

Admission

• There is a very rapid pulse (greater than 150 beats per minute) and/or low blood pressure (systolic blood pressure less than 90 mm Hg).

• There is loss of consciousness, severe dizziness, on-going chest pain, or increasing breathlessness.

• There is a complication of AF, such as stroke, TIA, or acute heart failure.

Routine referral to a cardiologist should be considered when:

• The person is young, eg less than 50 years of age.• Paroxysmal AF is suspected.• There is uncertainty regarding whether rate or

rhythm control should be used.• Drug treatments that can be used in primary care are

contra-indicated or have failed to control symptoms.• The person is found to have valve disease or left

ventricular systolic dysfunction on echocardiography.• Wolff-Parkinson-White syndrome or a prolonged QT

interval is suspected on the electrocardiogram.

Rhythm control

• Preferred in:• Patients with paroxysmal AF• Patients with persistent AF who are:

– Symptomatic– younger than 65 years– presenting for the first time with idiopathic AF or

secondary AF or with congestive heart failureIt should be started after specialist assessment.

Rate Control

Rate control may be started in primary care and is the preferred treatment when patients have:

• persistent AF• are more than 65 years old• have coronary artery disease• have contra-indications for cardioversion or

anti-arrhythmic drugs.

Rate Control• Ventricular rate control may be at least as

effective as restoration of sinus rhythm in terms of survival and symptom control, especially in elderly patients.[1]

Rate Control• Measure on an ECG or at the ventricular apex, not the wrist• Target below 80 beats per minute at rest and 90-115 on

moderate exercise.• A heart rate-limiting calcium-channel blocker (e.g verapamil

or diltiazem) or a beta-blocker are recommended as first-line therapy for control of the ventricular rate.

• Digoxin may control the resting heart rate, but rarely adequately controls heart rate during exertion and so should only be considered as monotherapy in predominantly sedentary patients. It may be added as a second-line therapy.

• Often a combination of two drugs may be needed and, in this case, digoxin can be combined with either a rate-limiting calcium-channel blocker or a beta-blocker.

ManagementRate Control:

You agree to start bisoprolol 2.5mg daily

Indications for planned cardioversion

• Persistent AF• Unable to achieve adequate rate control• Symptoms despite rate control• Age < 65• Recent onset and reversible precipitant eg

chest infection• Atrial Flutter

Management

CVA RISK?

NICE2006

CHA2DS2-VASc

CHADS2

CHADS2 score CVA rate per 100 pt years

0 1.91 2.82 4.03 5.94 8.55 12.56 18.2

CHADS2-NICE & QOFCHADS2 score Drug of choice

0 none or aspirin1 aspirin or warfarin>2 warfarin

European Society of CardiologyCHAD2 score of 1 = no or possible anticoagulation

and a score > 1 = anticoagulation

Explanation

How would you explain the risks of AF?

Anticoagulation

You would recommend warfarin

How do you have this conversation?

Warfarin in lower risk patients(1% per year)

Warfarin in moderate risk patients(3.5% per year)

Warfarin in high risk patients(6% per year)

http://sdm.rightcare.nhs.uk/pda/stroke-prevention-for-atrial-fibrillation/introduction/

Shared Decision Making

Warfarin Issues• Risk of bleeding• Daily medication• Other side effects• Blood monitoring• Other drug interactions

NOAC• Dabigatran (Pradaxa) 150 mg bd is more effective

than warfarin in reducing the risk of stroke or systemic embolism, ischaemic stroke and vascular mortality

• Rivaroxaban (Xarelto) 10 mg daily

Dabigatran• It does not require monitoring.• Compared with warfarin, overall risk of life-threatening

bleeds is reduced but there is an increased risk of a GI bleed. • NICE suggests it can be used in patients with non-valvular AF

with one or more of the following risk factors– previous stroke, TIA or systemic embolism, left ventricular ejection

fraction below 40%, symptomatic heart failure (NYHA class 2 or above)

– age 75 years or older or age 65 years or older with diabetes, coronary artery disease or hypertension.

• It can also be used in those patients with a poorly controlled INR currently on warfarin.

• Dabigatran 110 mg bd is appropriate for patients aged 80 years and above.

Rivaroxaban

• It does not require monitoring.• NICE suggests it can be used in patients with

non-valvular AF with one or more risk factors such as– congestive heart failure, hypertension, age 75 years

or older, diabetes mellitus, prior stroke or TIA.• It can also be used in those patients with a

poorly controlled INR currently on warfarin

Mr Chad Skorinski 76

Discharge letter received from hospital saying patient was discharged 2 weeks ago after developing a left sided hemiparesis

On admission he was noted to have

• left sided hemiparesis• AF rate 72• BP 130/72• CT showed small infarct

Patient made good improvement with OT / physio input and almost fully recovered function.

Commenced warfarin and bisoprolol 2.5mg od. Rate settle to 76 prior to discharge. Please arrange echo and AF follow up. Stroke rehab to continue.

Mr Chad Skorinski 76

PhxDiabetes 2002

Last encounter:2/2/12Diabetes review – ‘HBA1C 48 BP 130/80Bloods ok, still maintaining good glycaemic control on diet – review 12 months’

Issues

• Pulse checked before?• Significant event• Audit

• Coding• Check anti-coagulant team involved?• Refer echo• Review Mr Skorinski • Diabetes check due

QOF Indicators for AF 2013-141. Establish and maintain a register of patients with AF

2. Percentage of patients with AF in whom stroke risk has been assessed using the CHADS2 scoring system in the preceding 12 months (excluding those whose previous CHADS2 score is greater than 1).

3. In those patients with AF in whom there is a record of a CHADS2 score of 1 (latest in the preceding 12 months), the percentage of patients who are currently treated with anticoagulation drug therapy or antiplatelet therapy.

4. In those patients with AF whose latest record of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anticoagulation therapy.

The target resting heart rate in rate control management of AF is?

1. <1202. <1103. <1004. <905. <806. <70

Persistent AF

1. Subsides within 48 hours2. Lasts for more than 48 hours3. Lasts for more than 7 days4. Lasts for more than 28 days5. Lasts for more than 1 year

Which of the following statements about Dabigatran is incorrect?

• It does not require monitoring• It has a lower incidence of life-threatening

bleeds than warfarin• It has a lower incidence of GI bleeds than

warfarin• It should be used at a dose of 110mg bd in

patients over the age of 80• It is not suitable for patients with valvular

disease AF