THE MANAGEMENT OF ATRIAL FIBRILLATION

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THE MANAGEMENT OF ATRIAL FIBRILLATION

• DR. G. AMBEPITIYA
• MRCP(UK) MRCGP
• Clinical Lead in Cardiology
• City PCT.

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Atrial Fibrillation/Flutter

• Atrial tachyarrhythmia
• Electrical activity is disorganised
• AV node receives more impulses than it can
  conduct
• Most impulses are therefore blocked
• Results in an Irregular ventricular rhythm
• Deterioration of atrial mechanical function
• Leading to reduced cardiac output by 20

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Sinus Rhythm
AF
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ECHOMitral valve in M-mode
AML
A
B
A
B
PML
AF
Normal
A B Ventricular Diastole
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Prevalance

• Commonest cardiac arrhythmia
• Roughly doubles with each advancing decade.
• 0.5 - 50-59yrs
• increased to 9.0 - 80-89yrs
• Overall about 1 white population
• 3-5 of over 65 have AF
• 15 strokes occur in people with AF
• AF increases stroke risk 5-fold
• 2-8 TIAS occur in people with AF
  
  

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Classification of AF
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Easy way to remember
Intermittent and recurrent but terminates
spontaneously

• Paroxysmal AF -
• Persistant AF -
• Permanent AF -(long standing or chronic
  AF)

Requires cardioversion to return to SR
Cannot be terminated by cardioversion
or
Present for more than a year or
When cardioversion is not persued
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Causes of AF
Common
Other

• Congenital Ht disease
• Pulmonary embolism
• Infection
• Hypoxia
• Cardiac surgery
• Carditis
• Ca Bronchus

• Hypertension 14
• IHD
• Mitral valve Disease
• Alcohol
• Cardiomyopathies
• Hyperthyroidism
• Lone AF 14

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Consequences of AF

• Irregular rapid ventricular rate, loss of atrial
  contration,reducing filling of ventricle
• Reducing output further

• Decreased cardiac output
• Ischemia
• Hypotension
• Increased risk of clot formation in atria

Palpitations, dyspnoea
Chest pain
Dizziness, syncope
Thromboembolic TIA , stroke Systemic embolism
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Symptoms

• Asymptomatic
• Symptomatic

• Palpitations
• Dyspnoea
• Chest pain
• Dizziness, Syncope
• Neurological deficits for TIA, stroke
• Systemic embolism

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Role of GP in management of AF

• Diagnosis
• Identify causes
• Identify patients for referral
• Treatment
• to improve quality of life for patient
• Prevent complications

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Role of GP in management of AF

• Monitoring treatment
• optimum rate control
• minimizing risk of drug toxicity e.g. digoxin,
  amiodarone, warfarin
• drug interactions particularly with warfarin

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Suspect AF if patient has an irregularly
irregular pulse(can be regular in atrial
flutter)
Diagnosis
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ECG
P Waves
Steady baseline
Regular ventricular rate
No P Waves
Irregular undulating baseline
Irregularly irregular ventricular rate
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EXAMINATION- directed towards identifying causes

• BP,
• Heart murmurs
• Thyrotoxicosis
• Alcoholism
• Infections

• Co-morbidities - Diabetes,
  Heart failure
  

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Investigations

• FBS, FBC, RFT, TFT, LFT
• Valvular ht disease
• LV function
• Rarely myxomas, clots in LA
• Sick sinus syndrome
• brady-tachy syndrome
• Exercise induced AF , IHD
• IHD
• Intrinsic pulmonary pathology eg Ca lung,
  congenital heart disease, PE

• 1) Base line blood tests
• 2) Echo
• 3) Ambulatary ECG event recording
• 4) ETT
• 5) Coronary angiography
• 6) CxR

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Management

• To achieve sinus rhythm
• To achieve resting apex rate 60-80 /min
• To reduce undue increase of heart rate during
  exercise
• Anticoagulation or anti-platelet treatment
  

• 1) Rhythm control
• 2) Rate control
• 3) Prevention of thromboembolism

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GENERAL REMARKS

• Digoxin,Betablockers,Ca antagonists
• Aspirin 20
• Warfarin 68

• Drugs used in rate control have less side effects
  than those used in rhythm control
• Risk reduction of strokes

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RHYTHM CONTROL(CARDIOVERSION)

• More likely to succeed
• 1. Recent onset AF
• 2. No structural heart disease
• 3. Successful treatment of precipitating causes
  eg thyrotoxicosis, infection
• 4. Young age
• 5. Acute onset AF eg MI , Acute heart failure

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RHYTHM CONTROL(CARDIOVERSION)

• Less successful
• Does not require sedation
• Amiodarone 60
• Flecainide 60-90 but toxic side effects

• 1) Pharmacological
• 2) Electrical

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RHYTHM CONTROL(CARDIOVERSION)

• Digoxin
• Betablockers
• Verapamil

Very little ability to establish sinus rhythm
No effect on restoring sinus rhythm
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RHYTHM CONTROL(CARDIOVERSION)

• 1) Pharmacological
• 2) Electrical

• DC Shock 70-90 success
• Day procedure in hospital
• Needs sedation

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RHYTHM CONTROL(CARDIOVERSION)

• Associated with increased risk of thromboembolism
  during procedure
• Therefore warfarinise for 3 weeks prior to DC
  shock
• Or if onset of AF within 48 hours IV heparin
• All patients maintained for at least 4 weeks
  (usually longer) post DC shock

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RHYTHM CONTROL(CARDIOVERSION)

• If first electrical cardioversion successful and
  then reverts to AF later
• 2nd cardioversion attempted followed by
  medication to prevent recurrence
• eg amiodarone

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RHYTHM CONTROL(CARDIOVERSION)

• More likely to succeed
• 1. Recent onset AF
• 2. No structural heart disease
• 3. Successful treatment of precipitating causes
  eg thyrotoxicosis, infection
• 4. Young age
• 5. Acute onset AF eg MI , Acute heart failure

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Management

• To achieve sinus rhythm
• To achieve resting apex rate 60-80 /min
• To reduce undue increase of heart rate during
  exercise
• Anticoagulation or anti-platelet treatment
  

• 1) Rhythm control
• 2) Rate control
• 3) Prevention of thromboembolism

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Rate Control

• Patients unsuitable for cardioversion
• structural heart disease
• Comorbidity
• All patients with rapid AF initially to relieve
  symptoms
• Control achieved in slowing
• 1) Resting heart rate
• 2) Heart rate during exercise

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Rate Control

• Medications
• Betablockers (sotalol used in Paroxysmal AF)
• Digoxin
• Verapamil
• Diltiazem
• Dysopyramide
• Propafenone
• Quimidine
• Digoxin does not control rate during exercise
  well
• Betablockers and rate limiting Ca Antagonists
  control heart rate during exercise

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Rate Control

• Other medications
• Amiodarone
• Flecainide not used if LV function impaired
• Do not use betablockers and rate limiting
• Ca Antagonists together

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Management

• To achieve sinus rhythm
• To achieve resting apex rate 60-80 /min
• To reduce undue increase of heart rate during
  exercise
• Anticoagulation or anti-platelet treatment
  

• 1) Rhythm control
• 2) Rate control
• 3) Prevention of thromboembolism

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Thromboembolic prophylaxis

• Increased risk in patients with
• Hypertension
• Diabetes
• Previous TIAs
• Older patient
• 18 fold increase in risk in mitral stenosis
• 6 fold increase in non-valvular AF
• Ideally all patients with AF should receive
  aspirin or warfarin unless contraindicated

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Thromboembolic prophylaxis

• Aspirin reduces stroke by 20
• Warfarin reduces stroke by 60-68
• Maintain INR 2-3

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Thromboembolic prophylaxis

• Aspirin or warfarin
• Depends on the balance of overall risk of stroke
  compared with the risk of adverse effects
• Compliance
• Can patient have regular INR monitoring

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Thromboembolic prophylaxis

• Warfarin in AF
• A) High-risk Previous Stroke / TIA
• 90 events per 1000 (mainly strokes) prevented
• Benefits outweigh risk with warfarin treatment
• B) Moderate-risk Over 65 with no other risk
• factors for stroke
• 25 events per 1000 prevented,but 9 major
  bleeds
• Debatable whether benefits outweigh risks

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Thromboembolic prophylaxis

• Warfarin in AF
• C) Low-risk Below 65 with no other risk
• factors for stroke
• Aspirin rather than anticoagulants
• Aspirin also given to patients who are unwilling
  to take warfarin

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Thromboembolic prophylaxis

• Warfarin in AF
• Risk of major bleeding
• 1.3 with warfarin
• 1 control
• 3 in 1000 extra risk for major bleed
• 2 in 1000 extra risk for major ICH

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Thromboembolic prophylaxis

• Aspirin Warfarin
• Aspirin causes - slightly increased risk of ICH
• 1.2 per 1000
• - increased risk of GI bleed from
• ulceration and perforation
• - angioedema bronchospasm
• Enteric coated aspirin has 1/7 of antiplatelet
  activity compared to ordinary aspirin

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Thromboembolic prophylaxis

• Contraindications to Warfarin
• BP over 220/120
• Thrombocytopenia
• Haemophilia
• Liver Failure
• Renal Failure
• Peptic Ulcer

Oesophagal varices Aneurysm Proliferative
retinopathy Previous ICH Pregnancy
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Thromboembolic prophylaxis

• Contraindications to Warfarin
• Increased chance of trauma / falls
• Increased chance of GI bleeding from any cause
• Compliance
• Follow-up issues

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Management

• To achieve sinus rhythm
• To achieve resting apex rate 60-80 /min
• To reduce undue increase of heart rate during
  exercise
• Anticoagulation or anti-platelet treatment
  

• 1) Rhythm control
• 2) Rate control
• 3) Prevention of thromboembolism

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Thromboembolic prophylaxis

• Other treatments of AF
• AV ablation therapy Pacing
• Pulmonary vein ablation

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When to refer

• 1) Very symptomatic in need of urgent rate
  control
• acute AF, hypotension, acute heart failure,
  unstable angina
• Admit
• 2) Suitable for cardioversion - recent onset
• - no structural abnormalities
• - young age
• 3) Assessment of valves, LV function murmurs
• - cardiac failure

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When to refer (continued)

• 4) Syncope
• 5) Inadequate control despite maximum treatment
• 6) AF with broad ventricular complexes
• 7) AF with heart blocks, WPW syndrome

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CHAD2 Risk Assessment
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CHAD2 Risk Assessment
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Suspect AF if patient has an irregularly
irregular pulse(can be regular in atrial
flutter)
Diagnosis
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EXAMINATION- directed towards identifying causes

• BP,
• Heart murmurs
• Thyrotoxicosis
• Alcoholism
• Infections

• Co-morbidities - Diabetes,
  Heart failure
  

50
Investigations

• FBS, FBC, RFT, TFT, LFT
• Valvular ht disease
• LV function
• Rarely myxomas, clots in LA
• Sick sinus syndrome
• brady-tachy syndrome
• Exercise induced AF , IHD
• IHD
• Intrinsic pulmonary pathology eg Ca lung,
  congenital heart disease, PE

• 1) Base line blood tests
• 2) Echo
• 3) Ambulatary ECG event recording
• 4) ETT
• 5) Coronary angiography
• 6) CxR

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Management

• To achieve sinus rhythm
• To achieve resting apex rate 60-80 /min
• To reduce undue increase of heart rate during
  exercise
• Anticoagulation or anti-platelet treatment
  

• 1) Rhythm control
• 2) Rate control
• 3) Prevention of thromboembolism

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Summary
And use of thromboembolic prophylaxis
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And finally.

• AF can give rise to
• Debilitating strokes
• Systemic embolism blindness
• Heart failure
• Multi-infarct dementia
• Thereby causing
• Severe disability
• Restriction in mobility
• Social care dependency

All of these are preventable