9th October 2013 Dr Julian Tomkinson AF 9th October 2013 Dr Julian Tomkinson

Introduction 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”

Why is AF Important? AF prevalence rate in primary care is 1.2% 600,000 in England alone Atrial fibrillation predisposes patients to stroke, increasing stroke risk by 500-700% 12,500 strokes per year (of the 150,000 total) attributable to AF – 4,300 deaths in hospital – 3,200 discharges to residential care – 8,500 deaths within the first year DH Figures 2007

Consequences 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.

Type of AF Paroxysmal (subsides within 48 hours) Persistent ( >7days) Permanent (> 1 year)

Aetiology Idiopathic ('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 WPW Dilated 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 abuse Genetic: autosomal dominant

Detection Breathlessness Palpitations Syncope/dizziness Chest discomfort Stroke/TIA manual pulse palpation should be performed to assess for the presence of an irregular pulse that may indicate underlying AF

Detection Opportunistic 20% asymptomatic

Patients Attend for Many Reasons Medication reviews Chronic Illness monitoring Flu vaccination Just for a chat OPPORTUNITY TO CHECK PULSE

Making the Diagnosis ECG

Benefits Symptom Control Reduce Strokes, mortality, morbidity Reduce Cost to patients, families, social care, PCTs, NHS…………..

150,000 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: www.stroke.org.uk.

Scenario 1 WHAT DO YOU DO NEXT? Mrs April Fillingham 75 years old Attends for Flu Jab You take her pulse and it is irregularly irregular with rate 84 WHAT DO YOU DO NEXT?

Scenario 1 (continued) Mrs F says she feels well generally Past history of COPD She gets breathless running upstairs but put this down to COPD & age No chest pain

Scenario 1 (continued) Mrs F attends for ECG and bloods ECG shows AF rate 92 BP 136/87 FBC U+E’s TFTs glucose all ok INR 1

Risk factors Mrs AF No murmurs No recent acute chest infections Minimal alcohol intake No signs of heart failure

Scenario 1 (continued) What do you do now?

How do you explain to a patient they have AF? Explanation How do you explain to a patient they have AF?

Explanation “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

http://www.youtube.com/watch?v=wqau2_FQq1E

Useful resource RCGP Case Cards

Management

Admission There 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.

Routine 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.

Rhythm control Preferred in: Patients with paroxysmal AF Patients with persistent AF who are: Symptomatic younger than 65 years presenting for the first time with idiopathic AF or secondary AF or with congestive heart failure It should be started after specialist assessment.

Rate Control Rate control may be started in primary care and is the preferred treatment when patients have: persistent AF are more than 65 years old have coronary artery disease have contra-indications for cardioversion or anti-arrhythmic drugs.

Rate Control Ventricular rate control may be at least as effective as restoration of sinus rhythm in terms of survival and symptom control, especially in elderly patients.[1]

Rate Control Measure on an ECG or at the ventricular apex, not the wrist Target below 80 beats per minute at rest and 90-115 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.

Rate Control: You agree to start bisoprolol 2.5mg daily Management Rate Control: You agree to start bisoprolol 2.5mg daily

Indications for planned cardioversion Persistent AF Unable to achieve adequate rate control Symptoms despite rate control Age < 65 Recent onset and reversible precipitant eg chest infection Atrial Flutter

Management CVA RISK?

NICE 2006

CHA2DS2-VASc

CHADS2 CHADS2 score CVA rate per 100 pt years 0 1.9 1 2.8 2 4.0 3 5.9 4 8.5 5 12.5 6 18.2

European Society of Cardiology CHADS2-NICE & QOF CHADS2 score Drug of choice 0 none or aspirin 1 aspirin or warfarin >2 warfarin European Society of Cardiology CHAD2 score of 1 = no or possible anticoagulation and a score > 1 = anticoagulation

How would you explain the risks of AF? Explanation How would you explain the risks of AF?

How do you have this conversation? Anticoagulation You would recommend warfarin How do you have this conversation?

Warfarin in lower risk patients (1% per year)

Warfarin in moderate risk patients (3.5% per year)

Warfarin in high risk patients (6% per year)

Shared Decision Making http://sdm.rightcare.nhs.uk/pda/stroke-prevention-for-atrial-fibrillation/introduction/ Shared Decision Making

Warfarin Issues Risk of bleeding Daily medication Other side effects Blood monitoring Other drug interactions

NOAC Dabigatran (Pradaxa) 150 mg bd is more effective than warfarin in reducing the risk of stroke or systemic embolism, ischaemic stroke and vascular mortality Rivaroxaban (Xarelto) 10 mg daily

Dabigatran 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 factors previous 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.

Rivaroxaban It does not require monitoring. NICE suggests it can be used in patients with non-valvular AF with one or more risk factors such as congestive 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

Mr Chad Skorinski 76 Discharge letter received from hospital saying patient was discharged 2 weeks ago after developing a left sided hemiparesis On admission he was noted to have left sided hemiparesis • AF rate 72 • BP 130/72 • CT showed small infarct Patient 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.

Mr Chad Skorinski 76 Phx 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’

Issues Pulse checked before? Significant event Audit Coding Check anti-coagulant team involved? Refer echo Review Mr Skorinski Diabetes check due

QOF Indicators for AF 2013-14 Establish and maintain a register of patients with AF Percentage 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.

The target resting heart rate in rate control management of AF is? <120 <110 <100 <90 <80 <70

Persistent AF Subsides within 48 hours Lasts for more than 48 hours Lasts for more than 7 days Lasts for more than 28 days Lasts for more than 1 year

Which of the following statements about Dabigatran is incorrect? It does not require monitoring It has a lower incidence of life-threatening bleeds than warfarin It has a lower incidence of GI bleeds than warfarin It should be used at a dose of 110mg bd in patients over the age of 80 It is not suitable for patients with valvular disease AF