Presentation on theme: "9th October 2013 Dr Julian Tomkinson"— Presentation transcript:
19th October 2013 Dr Julian Tomkinson AF9th October 2013Dr Julian Tomkinson
2Introduction NICE 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”
3Why is AF Important? AF prevalence rate in primary care is 1.2% 600,000 in England aloneAtrial fibrillation predisposes patients to stroke, increasingstroke risk by %12,500 strokes per year (of the 150,000 total) attributableto AF– 4,300 deaths in hospital– 3,200 discharges to residential care– 8,500 deaths within the first yearDH Figures 2007
4Consequences 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.
5Type of AF Paroxysmal (subsides within 48 hours) Persistent ( >7days)Permanent (> 1 year)
6AetiologyIdiopathic ('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 WPWDilated 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 abuseGenetic: autosomal dominant
7Detection Breathlessness Palpitations Syncope/dizziness Chest discomfortStroke/TIAmanual pulse palpation should be performed to assess for the presence of an irregular pulse that may indicate underlying AF
11Benefits Symptom Control Reduce Strokes, mortality, morbidity Reduce Cost to patients, families, social care, PCTs, NHS…………..
12150,000 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:
13Scenario 1 WHAT DO YOU DO NEXT? Mrs April Fillingham 75 years oldAttends for Flu JabYou take her pulse and it is irregularly irregular with rate 84WHAT DO YOU DO NEXT?
14Scenario 1 (continued) Mrs F says she feels well generally Past history of COPDShe gets breathless running upstairs but put this down to COPD & ageNo chest pain
15Scenario 1 (continued) Mrs F attends for ECG and bloods ECG shows AF rate 92BP 136/87FBC U+E’s TFTs glucose all okINR 1
16Risk factors Mrs AF No murmurs No recent acute chest infections Minimal alcohol intakeNo signs of heart failure
18How do you explain to a patient they have AF? ExplanationHow do you explain to a patient they have AF?
19Explanation“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
23AdmissionThere 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.
24Routine 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.
25Rhythm control Preferred in: Patients with paroxysmal AF Patients with persistent AF who are:Symptomaticyounger than 65 yearspresenting for the first time with idiopathic AF or secondary AF or with congestive heart failureIt should be started after specialist assessment.
26Rate ControlRate control may be started in primary care and is the preferred treatment when patients have:persistent AFare more than 65 years oldhave coronary artery diseasehave contra-indications for cardioversion or anti-arrhythmic drugs.
27Rate ControlVentricular rate control may be at least as effective as restoration of sinus rhythm in terms of survival and symptom control, especially in elderly patients.
28Rate ControlMeasure on an ECG or at the ventricular apex, not the wristTarget below 80 beats per minute at rest and 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.
29Rate Control: You agree to start bisoprolol 2.5mg daily ManagementRate Control: You agree to start bisoprolol 2.5mg daily
30Indications for planned cardioversion Persistent AFUnable to achieve adequate rate controlSymptoms despite rate controlAge < 65Recent onset and reversible precipitant eg chest infectionAtrial Flutter
35European Society of Cardiology CHADS2-NICE & QOFCHADS2 score Drug of choice 0 none or aspirin 1 aspirin or warfarin >2 warfarinEuropean Society of CardiologyCHAD2 score of 1 = no or possible anticoagulation and a score > 1 = anticoagulation
36How would you explain the risks of AF? ExplanationHow would you explain the risks of AF?
37How do you have this conversation? AnticoagulationYou would recommend warfarinHow do you have this conversation?
42Warfarin Issues Risk of bleeding Daily medication Other side effects Blood monitoringOther drug interactions
43NOACDabigatran (Pradaxa) 150 mg bd is more effective than warfarin in reducing the risk of stroke or systemic embolism, ischaemic stroke and vascular mortalityRivaroxaban (Xarelto) 10 mg daily
44Dabigatran 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 factorsprevious 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.
45Rivaroxaban It does not require monitoring. NICE suggests it can be used in patients with non-valvular AF with one or more risk factors such ascongestive 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
46Mr Chad Skorinski 76Discharge letter received from hospital saying patient was discharged 2 weeks ago after developing a left sided hemiparesisOn admission he was noted to haveleft sided hemiparesis• AF rate 72• BP 130/72• CT showed small infarctPatient 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.
47Mr Chad Skorinski 76Phx Diabetes 2002 Last encounter: 2/2/12 Diabetes review – ‘HBA1C 48 BP 130/80 Bloods ok, still maintaining good glycaemic control on diet – review 12 months’
48Issues Pulse checked before? Significant event Audit Coding Check anti-coagulant team involved?Refer echoReview Mr SkorinskiDiabetes check due
49QOF Indicators for AFEstablish and maintain a register of patients with AFPercentage 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).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.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.
50The target resting heart rate in rate control management of AF is? <120<110<100<90<80<70
51Persistent AF Subsides within 48 hours Lasts for more than 48 hours Lasts for more than 7 daysLasts for more than 28 daysLasts for more than 1 year
52Which of the following statements about Dabigatran is incorrect? It does not require monitoringIt has a lower incidence of life-threatening bleeds than warfarinIt has a lower incidence of GI bleeds than warfarinIt should be used at a dose of 110mg bd in patients over the age of 80It is not suitable for patients with valvular disease AF