Atrial FibrillationAtrial Fibrillation

StatisticsStatistics

1.5% of people over 65 have AF1.5% of people over 65 have AF 5x increased risk of stroke5x increased risk of stroke 25% all strokes in elderly are caused by 25% all strokes in elderly are caused by

AFAF

So……Time for some NICE guidelines!So……Time for some NICE guidelines!

DiagnosisDiagnosis ECG on all pts where AF suspected because ECG on all pts where AF suspected because

of irregular pulse, regardless of whether or of irregular pulse, regardless of whether or not they have symptoms.not they have symptoms.

BMJ study in 2007 – ECG not a good BMJ study in 2007 – ECG not a good screening test for AF, would miss 20% screening test for AF, would miss 20% cases.cases.

A good Hx and pulse check is more A good Hx and pulse check is more effective.effective.

Paroxysmal AFParoxysmal AF not detected on routine ECG: not detected on routine ECG:24h ambulatory if ?asymptomatic episodes or 24h ambulatory if ?asymptomatic episodes or

<24h apart<24h apartEvent recorder if >24h apartEvent recorder if >24h apart

ManagementManagement

Acutely unwell – AdmitAcutely unwell – Admit Further Ix for causative factors, Further Ix for causative factors,

including ?echoincluding ?echo Rate V Rhythm controlRate V Rhythm control ThromboprophylaxisThromboprophylaxis ReferralReferral DrivingDriving

Who needs an Echo?Who needs an Echo?

Young ptsYoung pts If considering rhythm control If considering rhythm control

(electricity or drugs)(electricity or drugs) Possible structural heart disease Possible structural heart disease

(murmur, failure) – choice of (murmur, failure) – choice of antiarrhythmic agent.antiarrhythmic agent.

As part of risk assessment for stroke in As part of risk assessment for stroke in pts where need evidence of LV pts where need evidence of LV dysfunction or valvular heart disease.dysfunction or valvular heart disease.

Rate V Rhythm control Rate V Rhythm control first?first?

RateRateOver 65Over 65

Coronary artery Coronary artery diseasedisease

Unsuitable Unsuitable cardioversioncardioversion

Unsuitable for Unsuitable for antiarrhythmicsantiarrhythmics

RhythmRhythmUnder 65Under 65

Lone AFLone AF

CCFCCF

Secondary to treated Secondary to treated triggertrigger

Paroxysmal AFParoxysmal AF

Rhythm control – electricity Rhythm control – electricity and drugsand drugs

Acute AF < 48h durationAcute AF < 48h duration – speak to Medics about – speak to Medics about Electrical or Pharmacological (amiodarone, Electrical or Pharmacological (amiodarone, flecainide) cardioversion. Heparinize at presentation. flecainide) cardioversion. Heparinize at presentation.

No anticoag necessary if maintain SR after.No anticoag necessary if maintain SR after.

AF >48hAF >48h – Warfarin 3 weeks before (INR 2.5) or – Warfarin 3 weeks before (INR 2.5) or TOE.TOE.

If high R of AF recurrence then pre-treat with 4 If high R of AF recurrence then pre-treat with 4 weeks+ of amiodarone or sotalolweeks+ of amiodarone or sotalol

Warfarin for 4 weeks after procedure, or long term if Warfarin for 4 weeks after procedure, or long term if High R of stroke or Recurrence, eg: AF >12m, High R of stroke or Recurrence, eg: AF >12m, enlarged LA, prev recurrence.enlarged LA, prev recurrence.

Assess for need of long term antiarrhythmics….Assess for need of long term antiarrhythmics….

Post CardioversionPost Cardioversion

Consider antiarrythmic in anyone Consider antiarrythmic in anyone converted to SR who did not have a converted to SR who did not have a corrected precipitant eg: chest infection. corrected precipitant eg: chest infection. (Beta blocker first line).(Beta blocker first line).

Follow up at 1m and 6m to check still in Follow up at 1m and 6m to check still in SR.SR.

If SR at 6m then discharge back to GP.If SR at 6m then discharge back to GP. If relapse, then re-evaluate need for rate If relapse, then re-evaluate need for rate

V rhythm control.V rhythm control.

Rate ControlRate ControlBeta Blocker or

Rate Limiting Calcium Antagonist (diltiazem, verapamil)

Need better control normal activities (<110)Need better control during exercise (<220-age)

BBlocker OR RLCA with Digoxin

RLCA with Digoxin

Further rate control needed

Refer or Other drugs eg: amiodarone

Paroxysmal AFParoxysmal AF Thromboprophylaxis as appropriateThromboprophylaxis as appropriate ?Suitable for ?Suitable for “Pill in Pocket”“Pill in Pocket” : :One off dose of oral antiarrythmic to abort attack One off dose of oral antiarrythmic to abort attack

eg:flecainideeg:flecainideCriteria:Criteria:1.1. No LV dysfunction/ valvular or IHDNo LV dysfunction/ valvular or IHD2.2. Infreq symptomatic episodes of AFInfreq symptomatic episodes of AF3.3. SBP>100mmHg, Resting HR >70bpmSBP>100mmHg, Resting HR >70bpm4.4. Understand how and when to take medicationUnderstand how and when to take medication If unsuitable start standard BBlocker.If unsuitable start standard BBlocker. Try sotalol, amiodarone or flecainide if Rx fails, Try sotalol, amiodarone or flecainide if Rx fails,

then refer.then refer.

ThromboprophylaxisThromboprophylaxisParoxysmal, Permanent or Persistent AF

Assess Stroke/ Thromboembolism Risk

High Prev isch CVA/ TIA/ TE event>75 with HT, DM, Vasc dis

Echo evidence of LV dysf, failure, or valve disease

Moderate>65 with no High RFs

<75 with HT, DM, Vasc disease

Low<65 with

no mod or high RFs

Warfarin (INR 2.5)(Aspirin if contraindic)

Aspirin or Warfarin Aspirin 75-300mg/d

Referral for Specialist Referral for Specialist InterventionIntervention

Eg: Pacemaker, AV junction catheter Eg: Pacemaker, AV junction catheter ablation, atrial defibrillatorsablation, atrial defibrillators

Failed pharmacological RxFailed pharmacological Rx Lone AFLone AF ECG evidence of underlying ECG evidence of underlying

pharmacological disorder eg: WPWpharmacological disorder eg: WPW

AF and DrivingAF and Driving

Gp 1Gp 1

Must cease if Must cease if incapacitated by AF.incapacitated by AF.

Permitted if cause Permitted if cause ID’d and controlled ID’d and controlled for 4 weeks.for 4 weeks.

No need to notify No need to notify DVLA unless DVLA unless distracting/disablindistracting/disabling Sxg Sx

Gp 2Gp 2

Disqualifies if has Disqualifies if has caused or is likely to caused or is likely to cause incapacity.cause incapacity.

May be permitted May be permitted when:when:

Controlled for 3/12Controlled for 3/12

LV ejection fraction LV ejection fraction ≥0.4≥0.4

No other disqualifying No other disqualifying condition.condition.

Any QuestionsAny Questions