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Atrial Fibrillation

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Atrial Fibrillation Steve McGlynn Specialist Principal Pharmacist (Cardiology), Greater Glasgow and Clyde Honorary Clinical Lecture, University of Strathclyde – PowerPoint PPT presentation

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Title: Atrial Fibrillation


1
Atrial Fibrillation
  • Steve McGlynn
  • Specialist Principal Pharmacist (Cardiology),
  • Greater Glasgow and Clyde
  • Honorary Clinical Lecture,
  • University of Strathclyde

2
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3
Some types of arrhythmia
  • Supraventricular
  • Sinus Nodal
  • Sinus bradycardia
  • Sinus tachycardia
  • Sinus arrhythmia
  • Atrial
  • Atrial tachycardia
  • Atrial flutter
  • Atrial fibrillation
  • AV Nodal
  • AVNSVT
  • Heart blocks
  • Junctional
  • Ventricular
  • Escape rhythms
  • Ventricular tachycardia
  • Ventricular fibrillation

4
Atrial fibrillation
  • A heart rhythm disorder (arrhythmia). It usually
    involves a rapid heart rate, in which the upper
    heart chambers (atria) are stimulated to contract
    in a very disorganized and abnormal manner.
  • A type of supraventricular tachyarrhythmia
  • The most common arrhythmia

5
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6
Aetiology
  • Rheumatic heart disease
  • Coronary heart disease (MI)
  • Hypertension
  • Myopericarditis
  • Hypertrophic cardiomyopathy
  • Cardiac surgery
  • Thyrotoxicosis
  • Infection
  • Alcohol abuse
  • Pulmonary embolism
  • Caffeine
  • Exercise
  • Lone AF

7
Incidence / Prevalence
  • 1.7 / 1000 patients / year
  • 3 / 1000 patients / year (gt60 years)
  • 0.4 - 1 (overall)
  • 2 4 (gt60 years)
  • gt8 (gt80 years)

8
Classification
  • New / Recent onset
  • lt 48 hours
  • Paroxysmal
  • variable duration
  • self terminating
  • Persistent
  • Non-self terminating
  • Cardiovertable
  • Permanent
  • Non-self terminating
  • Non-cardiovertable

9
Symptoms / Signs
  • Breathlessness / dyspnoea
  • Palpitations
  • Syncope / dizziness
  • Chest discomfort
  • Stroke / TIA
  • 6 x risk of CVA
  • 2 x risk of death
  • 18 x risk of CVA if rheumatic heart disease
  • Irregularly irregular pulse
  • Atrial rate
  • 300-600bpm
  • Ventricular rate depends on degree of AV block
  • 120-160bpm
  • Peripheral rate slower (pulse deficit)

10
Investigations
  • Electrocardiogram (ECG)
  • All patients
  • May need ambulatory monitoring
  • Transthoracic echocardiogram (TTE)
  • Establish baseline
  • Identify structural heart disease
  • Risk stratification for anti-thrombotic therapy
  • Transoesophogeal echocardiography (TOE)
  • Further valve assessment
  • If TTE inconclusive / difficult

11
Normal Sinus Rhythm
12
Fast AF
13
Slow AF
14
Atrial Flutter
15
Investigations
  • Electrocardiogram (ECG)
  • All patients
  • May need ambulatory monitoring
  • Transthoracic echocardiogram (TTE)
  • Baseline
  • Structural heart disease
  • Risk stratification for anti-thrombotic therapy
  • Transoesophogeal echocardiography (TOE)
  • Further valve assessment
  • TTE inconclusive / difficult

16
Diagnosis
  • Based on
  • ECG
  • Presentation
  • Response to treatment

17
Treatment objectives
  • Rhythm / rate control
  • Stroke prevention

18
Treatment strategies
  • New / Recent onset
  • Cardioversion
  • Rhythm control
  • Paroxysmal
  • Rate control or cardioversion during paroxysm
  • Rhythm control if needed
  • Persistent
  • Cardioversion
  • Rhythm control
  • Peri-cardioversion thromboprophylaxis
  • Permanent
  • Rate control
  • Thromboprophylaxis

19
Pharmacological Options
  • Class Ic Anti-arrhythmics
  • Flecainide / Propafenone
  • Rhythm control
  • May also be pro-arrhythmic
  • Class II Anti-arrhythmics
  • Beta-blockers
  • Mainly rate control
  • Control rate during exercise and at rest
  • Generally first choice
  • Choice depends on co-morbidities

20
  • Class III Anti-arryhthmics
  • Amiodarone / Dronedarone
  • Mainly rhythm control
  • May be pro-arrhythmic
  • Concerns over toxicity
  • Class IV Anti-arryhthmics
  • Calcium channel blockers (verapamil / diltiazem
    only)
  • Rate control only
  • Alternative to beta-blockers if no heart failure
  • Digoxin
  • Rate control only
  • Does not control rate during exercise
  • Third choice unless others contra-indicated

21
Acute AF
  • Treatment will depend on
  • History of AF
  • Time to presentation (ltgt 24 hours)
  • Co-morbidities (CHD, CHF/LVSD etc)
  • Likelihood of success (History)

22
  • Rate Vs. Rhythm control
  • Rhythm control not feasible or safe
  • Beta-blocker
  • Verapamil
  • Digoxin (CHF)
  • Rhythm control if possible and safe
  • DC cardioversion (if possible)
  • Amiodarone (CHD or CHF/LVSD)
  • Flecainide (Paroxysmal AF)

23
Paroxymal AF
  • Rhythm control
  • Beta-blocker
  • Class 1c agent or sotalol
  • If CHD - sotalol
  • If LVD Amiodarone
  • Dronedarone?
  • May be Pill in the pocket
  • Antithrombotic therapy as per risk assessment
  • Aspirin 75-300mg
  • warfarin to INR 2-3
  • See later

24
Persistent AF
  • Rhythm control
  • Beta blocker
  • No structural heart disease Class 1c or sotalol
  • Structural heart disease amiodarone
  • Rate control
  • As for permanent AF
  • not if CHD present
  • Antithrombotic therapy as per risk assessment
  • Pre-cardioversion thromboprophylaxis of at least
    3 weeks
  • If rate control, as for permanent AF

25
Permanent AF
  • Beta blocker or
  • Calcium channel blocker and/or
  • Digoxin
  • Amiodarone?
  • Antithrombotic therapy as per risk assessment
  • Aspirin 75-300mg
  • Warfarin to INR 2-3
  • See later

26
Stroke prevention (non-rheumatic AF)
27
Stroke Risk Assessment (CHADS2)
  • C Chronic Heart Failure (1 point)
  • H Hypertension (1 point)
  • A Age gt 75 years (1 point)
  • D Diabetes (1 point)
  • S Stroke, TIA or systemic embolisation (2 points)
  • Score lt 2 low risk, aspirin or anticoagulant
  • Score 2 high risk, anticoagulant indicated

28
Stroke Risk Assessment (CHA2DS2VASc)
  • Alternative to CHADS2
  • C Chronic Heart Failure (1 point)
  • H Hypertension (1 point)
  • A Age gt 75 years (2 points)
  • D Diabetes (1 point)
  • S Stroke, TIA or systemic embolisation (2 points)
  • V vascular disease (1 point)
  • A Age 65-74 years (1 point)
  • Sc Sex category (1 point if female)

29
Bleeding Risk Assessment(HAS-BLED)
  • 1 point each for
  • Hypertension
  • Abnormal renal/liver function (1 for each)
  • Stroke
  • Bleeding history or predisposition
  • Labile INR
  • Elderly (age over 65)
  • Drugs/alcohol concomitantly (1 for each)
  • Drugs that increase bleeding, e.g. aspirin
  • Alcohol excess

30
Anticoagulants
  • Warfarin remains standard anticoagulant at
    present
  • 3 new oral anticoagulants (unlicensed for AF as
    of June 2011)
  • Dabigatran (Direct thrombin inhibitor)
  • Rivaroxiban (Factor Xa inhibitor)
  • Apixaban (Factor Xa inhibitor)
  • Fixed doses
  • No monitoring
  • At least as effective as warfarin
  • Safer than warfarin?
  • Much more expensive (even allowing for INR costs)
  • Place in therapy not clear yet

31
Conclusions
  • AF is a common condition.
  • Patients may be unaware of its presence and are
    therefore at risk of a stroke
  • Alternative treatment strategies exist to control
    symptoms
  • Alternative treatment strategies exist to reduce
    the risk of stroke
  • Patient education and choice are central to
    improving the likelihood of treatment success
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