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Atrial Fibrillation Cardiovascular ISCEE 26 th October 2010.

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Presentation on theme: "Atrial Fibrillation Cardiovascular ISCEE 26 th October 2010."— Presentation transcript:

1 Atrial Fibrillation Cardiovascular ISCEE 26 th October 2010

2 How might AF present in GP? People with an irregular pulse +/- Breathlessness Palpitations Chest discomfort Syncope/dizziness Reduced exercise tolerance, malaise or polyuria A potential complication of AF such as stroke, TIA or heart failure

3 Absence of an abnormal pulse makes a diagnosis of AF unlikely But its presence does not reliably indicate AF. Suspect paroxysmal AF if symptoms are episodic and last less than 48 hours.

4 What do we need to do with them? ECG to confirm diagnosis If paroxysmal AF suspected and 12-lead ECG is normal then arrange ambulatory electrocardiography Bloods CXR

5 TFTs – exclude hyperthyroidism FBC – exclude anaemia U&Es, Bone Profile, Glucose – exclude electrolyte disturbances which may precipitate AF LFTs and clotting screen – assess suitability for warfarin CXR – exclude lung abnormality such as lung cancer, also to detect heart failure

6 Which ones need to be referred? Urgently Patients with: Pulse > 150 bpm and/or low BP (systolic less than 90 mmHg) Loss of consciousness, severe dizziness, ongoing chest pain or increasing breathlessness A complication of AF – stroke, TIA, acute HF

7 Which ones need to be referred? Outpatients New onset AF + Young patient (age less than 50 yrs) Suspected paroxysmal AF Concurrent valve disease LV systolic dysfunction on echo Wolff-Parkinson-White syndrome or a prolonged QT interval is suspected on the ECG Heart rate is difficult to control Person continues to have symptoms despite rate control treatment

8 Rhythm vs Rate Rhythm control preferred treatment for paroxysmal AF and in people with persistent AF with any of the following: Symptomatic < 65 yrs of age First presentation with lone AF AF secondary to a treated or corrected precipitant (eg infection) Congestive heart failure Rate controlled preferred treatment for permanent AF and in people with persistent AF and any of the following: > 65 yrs age Coronary artery disease Contraindications to antiarrhythmic drugs Unsuitable for cardioversion

9 GP Management Rate control can be started in primary care Beta-blockers, rate-limiting Ca-channel blockers, digoxin) But rhythm control should only be done under specialist supervision Amiodarone, fleicanide, sotalol Start rate-control anyway if the person does not need admission but Resting pulse >/= 90 bpm Heart rate is fast on exertion, resulting in limited exercise tolerance

10 Initial Rate Control Treatment Beta-blocker or rate limiting Ca-channel blocker (diltiazem or verapamil) unless this is contraindicated Choice between the 2 groups depends on current medication and co-morbidities Diltiazem preferred to verapamil because verapamil has a greater negative inotropic effect and interacts with digoxin Digoxin suitable for older sedentary people in whom rate control is not needed during exercise

11 Subsequent Management Review within 1 week – is the patient tolerating the drug? Review symptoms, heart rate, BP. If drug not tolerated, prescribe an alternative. If symptoms not controlled, either increase dose or consider combination treatment. To control symptoms during normal activities only, use beta-blocker/Ca-blocker with digoxin. To control symptoms normal activities AND during exercise, use Ca-blocker with digoxin.

12 Subsequent Management Do not use a beta-blocker and Ca-blocker to control AF in primary care If symptoms are not controlled by beta-blocker plus digoxin OR Ca-blocker plus digoxin refer to cardiology

13 Antithrombotic Treatment Everyone with AF (paroxysmal, persistent, permanent) should be offered antithrombotic treatment to reduce their risk of stroke Offer either aspirin or warfarin without delay after confirming a diagnosis of AF Choice should be based on persons risk of stroke Assess bleeding risk, likelihood of compliance with treatment and preferred options Low risk of stroke – aspirin Moderate risk of stroke – either aspirin or warfarin High risk of stroke – warfarin

14 Assessing Bleeding Risk Factors that increase risk of bleeding Age > 75yrs Use of antiplatelet drugs Use of NSAIDs Polypharmacy Uncontrolled hypertension Hx of bleeding (bleeding peptic ulcer, cerebral haemorrhage) Hx of previous poorly controlled anticoagulation therapy

15 Assessing Stroke Risk High risk Previous ischaemic stroke / TIA or thromboembolic event > 75yrs age with risk factors (hypertension, diabetes, coronary artery disease, peripheral artery disease) Clinical evidence of valve disease or heart failure Impaired LV function on echo Moderate risk > 65yrs age without risk factors < 75yrs age with risk factors Low risk < 65yrs age without risk factors

16 CHADS2 Congestive heart failure = 1 Hypertension (or treated hypertension) = 1 Age older than 75 years = 1 Diabetes mellitus = 1 previous Stroke or TIA = 2 Treat with aspirin if total score is 0 or 1 Use warfarin if score is 2 or more

17 References NICE 2006 Atrial Fibrillation Clinical Knowledge Summaries: Atrial Fibrillation

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