1. Atrial Fibrillation Service
Jayne Woolley
Arrhythmia Specialist Nurse
Royal Glamorgan Hospital
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2. Atrial Fibrillation Service
In-patient referrals for New onset/Incidental finding AF
Advice and support to medical team
Provision of patient information and counselling
Weekly AF MDT meeting
Follow-up clinics
Dronedarone – monthly monitoring
Anticoagulation/NOAC counselling initiation

3. Atrial fibrillation Service
Both Rate/Rhythm control need :
Stroke risk assessment
CHADS2 – 0/1 reassess risk
CHA2DS2VASc score
1 anticoagulation to be considered
2 anticoagulation recommended

4. Atrial Fibrillation Service
HASBLED score
Hypertennsion
(systolic > 160mmHG) point
Abnormal renal/liver function
(chronic dialysis/transplantation,
serum creatinine >200mmol/L
chronic hepatic disease, bilirubin 2 x upper limit
alkaline phosphatase 3 x upper limit 1 point each
Stroke point
Bleeding point
previous bleeding history, anaemia etc
Liable INR’s point
< 60% in theraputic range, unstable high INRs
Elderly
> 65yrs of age point
Drugs/Alcohol
concomitant use of drugs , antiplatelet agents,
alcohol abuse point each
SCORE OF >3 HIGH RISK

5. Atrial Fibrillation Service
NOAC s for stroke prevention in adults with non-valvular AF
with 1 or more risk factors:
Stroke/TIA/Systemic embolism
Symptomatic heart failure (NYHA) class >2
Left ventricular failure, ejection fraction <40%
Age >75 yrs
Age >65 plus one of the following:
Diabetes mellitus, coronary artery disease or hypertension
Dabigatran, Apixaban and Rivaroxaban
Pros: Cons:
Lower intercranial haemorrhage No known reversible agent
Rapid onset/short half life No monitoring
No monitoring Heartburn/bloating/diarrhoea
No food restrictions % compliance
No alcohol restrictions
Less drug interactions

6. Atrial Fibrillation Service
Elective cardioversion
Receive referrals
Arrange anticoagulation and required investigations
Recording weekly INR results (warfarin)
Pre-assessment clinics
If on NOAC declaration is signed by patient
Cardioversion procedure
1 + 6 month follow-up clinics

7. Atrial Fibrillation Service
Elective cardioversion
every 4 weeks
5-6 patients per list
13 currently waiting
at least 2 extra lists per year

8. Waiting Times for Cardioversion
Min
4 Weeks
Max
12 Weeks
Longer if subtheraputic INR

9. Atrial Fibrillation Service
Cardioversion April 2013-April 2014
88 patients listed 2 extras lists
82 successful %
6 unsuccessful on the day - 7% (rounded up) max 3 shocks delivered, AF in theatre

10. Cancellations and Deferred Patients April 2013 – April 2014
5 – SR on workup/Pre-assessment
Deferred
2 – raised TSH (above 10)
12 – low INR
* If any of these issues caused a schedule delay or need to be discussed further, include details in next slide.

11. Atrial Fibrillation Service
Pre/Post cardioversion
Weekly INRs 3 weeks before
Preferred range 2.5 to 3.0 (reduced risk of stroke at higher
level) if INR below 2 in the 3 weeks then they are cancelled
Weekly INRs 4 weeks post cardioversion
level)
ESC and NICE state that anticoagulation should continue and not be interrupted for minimum of 4 weeks post cardioversion
Thromboembolic complications of direct cardioversion are generally related to inadequate intensity of anticoagulation. The INR at the time of conversion is very important. Anticoagulation is necessary for the conversion of atrial flutter as it is for atrial fibrillation. The INR should be 2.5 or more at the time of cardioversion of any atrial arrhythmia that has lasted for more than 2 days.
J Am Coll Cardiol 2002

12. Thank You!