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Atrial Fibrillation Service Jayne Woolley Arrhythmia Specialist Nurse Royal Glamorgan Hospital.

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Presentation on theme: "Atrial Fibrillation Service Jayne Woolley Arrhythmia Specialist Nurse Royal Glamorgan Hospital."— Presentation transcript:

1 Atrial Fibrillation Service Jayne Woolley Arrhythmia Specialist Nurse Royal Glamorgan Hospital

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) 1 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 1 point Bleeding 1 point previous bleeding history, anaemia etc Liable INR’s 1 point < 60% in theraputic range, unstable high INRs Elderly > 65yrs of age 1 point Drugs/Alcohol concomitant use of drugs, antiplatelet agents, alcohol abuse 1 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 100% 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 – 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 Min 4 Weeks Max 12 Weeks Longer if subtheraputic INR Waiting Times for Cardioversion

9 Atrial Fibrillation Service Cardioversion April 2013-April patients listed 2 extras lists 82 successful - 93% 6 unsuccessful on the day - 7% (rounded up) max 3 shocks delivered, AF in theatre

10 Cancellations and Deferred Patients April 2013 – April 2014 Cancellations o 5 – SR on workup/Pre-assessment Deferred o 2 – raised TSH (above 10) o 12 – low INR

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 Preferred range 2.5 to 3.0 (reduced risk of stroke at higher 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!


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