Atrial Fibrillation, AntiCoagulation Mahesh Pauriah Consultant Cardiologist & Cardiac Electro- physiologist

Case 1 74 year old lady Routine visit Irregularly irregular pulse on examination Mild SOB on moderate exertion PMH: Hypertension Meds: valsartan Allergies Nil Examination: HR 115 bpm , BP 135/76 mmHg Heart sounds normal – chest clear

Bloods: 2 weeks ago FBC: Hb 12.5 mg/dl, Normal Renal function TFTs Normal What would you do? – patient feels well

Rate control Ant coagulate

Rate control : beta blocker – Bisoprolol 2 Rate control : beta blocker – Bisoprolol 2.5 mg BD , calcium channel blocker if asthma +/-Digoxin Bisoprolol 2.5 mg BD , increase to 3.75 mg BD, then 5 mg DB- then change to once a day meds Aim for a resting HR < 90 bpm

Anticoagulate : CHADSVasc Score Warfarin Xorelto , Dabigatran, Apixiban ? DC Cardioversion

Dental Issues Endoscopy / Colonoscopy Surgery PCI- antiplatelets

6 Months later – complains of increasing SOB, Bilateral ankle oedema Orthopnoea/ PND ECG: Rate control AF ECHO – severe LV Impairment.

Heart Failure Meds- ACE inhibitor Diuretics Spironolactone. Optimise meds

GI Bleeding

Atrial Fibrillation AF is very common More common in men than women. AF rates in the population increases with increasing age. lifetime risk of atrial fibrillation has been estimated to be 1 in 5 of the population

Background

Change with Time

Types of Atrial Fibrillation (1) Paroxysmal AF is self-terminating, usually within 48 h (2) Persistent AF: defined if AF episode either lasts longer than 7 days or requires termination by cardioversion, either with drugs or by direct current cardioversion (DCC) (3) Long-standing persistent AF : if AF is present for ≥1 year

Natural History

Strategies to Treat AF ANTICOAGULATION RATE vs RHYTHM CONTROL

Risk of Stroke

Left Atrial Appendage Thrombus

Risk of Stroke Determine The Risk of Stroke Risk of Bleeding with anticoagulation CHADS Score or CHADSVASC Score

CHADSVASC and Risk of Stroke

Anticoagulation Warfarin – Keep INR between 2-3 NOAC Dabigatran Rivoraxaban Apixiban Endoxaban

Tachy-Brady Syndrome

Symptomatic or poor heart rate control/ Intolerant to Meds

Anticoagulation Based on ChadsVasc Score Rate Vs Rhythm Control For asymptomatic Patients rate control as good as rhythm control Aim for resting HR < 90 bpm and < 110 bpm on exercise For symptomatic patients- try to keep sinus rhythm Trial of cardioversion for most patients

Rate Control Beta Blockers Bisoprolol – start small and increase dose Digoxin – may need to dose a level 6 nours post dose Addition of Digoxin to Beta Blockers may reduce the dose of Beta Blockers required Calcium channel Blockers- eg Diltiazem/ Verapamil- use with caution- Heart Failure

Case Study 2 35 year old man Marathon Runner Episodes of Irregular Irregular Heart rhythm Lasts for 4-6 hours Bloods Normal ECG Normal Echo Normal Several Holter monitor Normal

Modern Technology

ALIVECOR

Example of Transmission

Diagnosis Paroxysmal Atrial Fibrillation Treatment Medical Ablation

Medical Management of AF Reassurance- this is not not going to lead to death/heart attack Refrain from Binge Drinking Relax “Ride it out” Seek help if unwell Pill in the pocket Flecainide & Beta Blockers

Flecainide Excellent Drug However, can lead to arrhythmia Make sure ECG Normal ECHO Normal No Evidence of Coronary Artery Disease Danger with Atrial Flutter and Flecainide alone

Atrial Fibrillation Ablation For Troublesome symptomatic AF

Atrial Fibrillation Ablation

Success Rates Success rates variable Works well with Paroxysmal AF Redo rates Less well with Persistent Poor with Longstanding Persistent AF

Complications Stroke- 1:200 Use Heparin intra-procedural Groin Haematoma – requiring Intervention 1:200 Tamponade 1:200 Emergency Operation or Death 1: 1000

Stroke in Young Man 40 year old man PMH: Nil Meds : Nil Allergies: Nil Admitted with Stroke Good Recovery

Investigations Bloods Normal , Including vasculitis Screen MRI Confirms CVA ECG ECHO Bubble Echo Holter Monitor – Normal

Bubble Echo

What Next

How to Implant

Automatic Transmission

Unrelated Case 65 year old man with sudden LOC a few weeks ago Seen in AE – discharged Seen at MPH – ECG/Echo /ETT Normal Holter Normal Loop Recorder

Plan: Bloods/ TFTs Anticoagulation

Anticoagulate Holter monitor – to ascertain rate control DC Cardioversion -3 weeks before and 4 weeks afterwards

Case 3 84 year old Dizzy spells Bisoprolol 10 mg OD Diltiazem PMH: Hypertension Meds: As above

Admit Stop all rate limiting drugs Anticoagulation Monitor – BP stable No temporary wire HR settled mild tachycardia after 4 days. Started on Bisoprolol 1.25 mg OD- HOME no pacemaker . Well 9 months later

Case 4 76 year old man Previously well January – fell Subdural Haematoma 2 weeks in CUH Treated Conservatively Asprin Stopped

PMHX : Hypertension Discharged 2 weeks later Change in Personality Dizzy,

Recurrent admissions to Hospital since then – repeat CT bleed getting better Noted to have an irregular pulse Holter : Episodes of atrial Flutter

ECG

Discussed with Neurosurgery Admitted to Hospital Rate controlled Bisoprolol / Digoxin – Discussed with Neurosurgery Risk of bleeding high Repeat Scan in 2 weeks CHADSVasc Score 3:

Atrial flutter Ablation

Atrial Flutter

Repeat CT Scan today – SDH almost resolved Can go on a NOAC

Case 5 78 year old gentleman Previous Bowel cancer Treated with surgery and radiation – 5 years ago 6 months history of SOB and palpitations

Examination : Gross heart failure Treated with diuretics Rate control : Digoxin and beta blockers Ramipril 5 mg BD Spironolactone Warfarin Echo : EF of about 20% [ normal > 50%]

Much better rate control Discharged Home Heart rate settled Much better rate control Discharged Home Medications on Discharge Warfarin Bisoprolol 10 mg Digoxin 125 mcg Ramipril 2.5 mg OD Spironolactone 25 mg OD

Medications Optimised Warfarin Ramipril 5 mg BD Bisoprolol 10 mg Digoxin

3 months later NYHA 3 On Optimal Meds Anti coagulated- Recurrent PR Bleeds LBBB and rate controlled AF

Treatment options for patients with chronic symptomatic systolic heart failure (NYHA functional class II–IV). Treatment options for patients with chronic symptomatic systolic heart failure (NYHA functional class II–IV). Authors/Task Force Members et al. Eur Heart J 2012;33:1787-1847 © The European Society of Cardiology 2012. All rights reserved. For permissions please email: journals.permissions@oup.com

Biventricular Pacemaker

Amiodarone – well loaded Cardioverted EF almost normal NYHA 1 Almost back to normal . Recurrent bleeds requiring transfusion

Changed warfarin to Apixiban 5 mg BD Still PR Bleed- requiring transfusion

Lower dose of NOAC- bleed SR for 6 months- stop all anticoagulants Declined watchman Lower dose of NOAC- bleed SR for 6 months- stop all anticoagulants Atrial Fibrillation alarm

Cardiac Electrophysiology, Arrhythmia & Heart Failure

Drugs for Heart Failure

Heart Failure

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