Atrial Fibrillation. CVD Clinical Development Coordinator

Transcription

1 Atrial Fibrillation CVD Clinical Development Coordinator

2 Atrial Fibrillation What it is and why it's important Case identification Heart rate control and onward referral Managing AF-Related Stroke risk Overview of anti-arrhythmic drugs Life-long monitoring issues

3 Atrial Fibrillation (AF) I million people in the UK diagnosed with AF 5-fold increased stroke risk AF related strokes often fatal or severe 15% of those aged over 75 years have AF AF is often undetected and untreated

4 Atrial Fibrillation

5 Classification of AF subtypes First diagnosed episode of atrial fibrillation Paroxysmal (usually 48 Hrs) Persistent Long Standing (persistent > 1year) Permanent (accepted) 11. European Heart Journal (2010) 31,

6 Cardiovascular and other conditions associated with atrial fibrillation Ageing Hypertension Heart Failure Tachycardiomyopathy Valvular Heart Disease Cardiomyopathies Atrial septal defect Other congenital heart defects Coronary Heart Disease Thyroid dysfunction Obesity Diabetes COPD/Sleep Apnoea Chronic Renal Disease

7 Management Goals Atrial Fibrillation Exclude/treat underlying cause Reduce Thromboembolic risk Prevent circulatory instability Rate/rhythm Control

8 Signs & Symptoms Shortness of breath on exercise or at rest Dizziness Tiredness Palpitations Can be very frightening for the patient Embolic episode Chest pain Falls Or no symptoms at all

9 Detection Remember a third of cases are asymptomatic so we need to check for it

10 Case Identification Pulse checks in high risk groups ECG needed to diagnose AF (interpreted by someone competent at reading ECGs) 24-Hour (or longer) heart monitor maybe needed to capture paroxysmal AF National Initiatives Identify AF before morbidity or mortality!

11 Mrs Cynthia Davies Mrs Davies is an 80 year old lady who lives alone. She manages with support from her daughter. She has always been quite healthy and has come today for a blood pressure check. You manually palpate her pulse first and notice that it is irregular. What are the issues here and what needs to happen next?

12 Atrial fibrillation

13 Cynthia Davies - ECG confirms Atrial Fibrillation Assessment of symptoms Physical assessment Request further Tests (bloods, echo, 24 hour Holter) Patient education and support Assessment of stroke risk Discussion of treatment options (Rate and/or Rhythm control) Personalised package of care developed and documented

14 A range of questions and concerns that may need to be addressed with those newly diagnosed with AF (adapted from NICE, 2014 What is AF? What is my stroke risk? Which option to reduce this risk is best for me? Why do I need more tests? How will rate control help? Who do I contact if unwell, need more support or want to access further information? What other treatment options are there?

15 Mrs Cynthia Davies 80 yrs old with new onset atrial fibrillation PMH: Hypertension and osteoarthritis Manual blood pressure:110/76 mmhg and 104/74 mmhg (sitting/standing) Radial pulse rate: 86 bpm (irregular) ECG: atrial fibrillation 112 bpm Medication Amlodipine 10mg daily Losartan 50mg daily Paracetamol as required Blood tests satisfactory (U&E, Fbc, TFT, LFT and clotting)

16 Why control heart rate in Atrial Fibrillation? Minimise symptoms Prevent tachycardia associated cardiomyopathy

17 What drugs would you use for HEART RATE control? A.) Beta-Blocker Diltiazem or Beta- Blocker C.) Digoxin D.) Not needed L F

18 Heart Rate Control in Atrial Fibrillation Beta-blocker Diltiazem (if beta-blocker contraindicated) Digoxin as an additional agent to optimise rate control, where required or as monotherapy only in predominantly sedentary patients

19 Digoxin Toxicity Risk of Toxicity Increased with: Medications: Calcium Channel Blockers, Quinidine, Amiodarone, Diuretics, Propafenone, Indomethacin) Age Electrolyte imbalance: Hyper/hypokalaemia, hypomagnesemia, hypercalcaemia and hypernatraemia Metablolic problems: Hypothyroidism, hypoxaemia and alkalosis

20 Type of medication Common Side-effects Monitor Beta-Blocker (that is, a beta-blocker other than sotalol) Bronchospasm (thus contraindicated with asthma) Bradycardia, hypotension Fatigue Cold extremities sleep disturbance with nightmares Symptoms, blood pressure, heart rate and renal function. Diltiazem (Rate-limiting calcium antagonist) (Unlicensed indication) Digoxin (Non-paroxysmal AF only) Bradycardia palpitation, dizziness, hypotension, malaise, asthenia, headache, hot flushes, gastro-intestinal disturbances, oedema (notably of ankles); Nausea, vomiting, diarrhoea; arrhythmias, dizziness; blurred or yellow vision; rash, eosinophilia Symptoms, blood pressure and heart rate Symptoms In renal impairment reduce dose and monitor plasma-digoxin concentration; toxicity increased by electrolyte disturbances If experiencing side-effects check a venous digoxin level to check for DIGOXIN TOXICITY Adapted from NICE, 2014 and ebnf July 2015, downloaded Refer to BNF for full contraindication, dosage and side-effect information

21 On-going Symptoms? Refer people promptly at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed.

22 Rhythm Control of AF Options for patients with recent onset may include: Cardioversion Ablation Surgery

23 DVD Clip of Cardioversion and/or ablation?

24 In order to reduce the risk of stroke, a 65 year old patient with atrial fibrillation should be considered for A.) Aspirin C.) Anti-coagulation and Aspirin B.) Anti-coagulation or Aspirin D.) Anti-coagulation L F

25 Calculate the stroke risk CHA2DS2-VASc Score (for non-valvular AF)

26 Calculate stroke risk score with: symptomatic, asymptomatic, paroxysmal, persistent or permanent atrial fibrillation atrial Flutter a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm Do not offer Aspirin monotherapy solely for stroke prevention to people with atrial fibrillation *National Clinical Guideline Centre (NCGC) 2014 **The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC )

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28 Cynthia Davies Stroke Risk: CHA2DS2-VASc Score C H A D S V A Sc Congestive heart failure? Hypertension Age >75 yrs Diabetes Stroke,TIA or thromboembolism Vascular disease Age Sex category (female) Points (max 9) So even without the echo result we know her score is at least 4 and therefore she is at significant stroke risk 1 point for female gender alone would NOT be an indication for anticoagulation

29 CHA2DS2-VASc score 4 NICE: anticoagulant options decision aid

30 Bleeding Risk: HAS-BLED H Hypertension 1 A Abnormal renal and liver function* 1 or 2 S Stroke 1 B Bleeding 1 L Labile INRs 1 E Elderly >65years 1 D Drugs eg aspirin, NSAID, alcohol* 1 or 2 *1 point each. A Score >=3 indicates high risk Therefore, caution required with either anti-platelet or oral anticoagulant therapy

31 Bleeding Risk: HAS-BLED A score of >3 indicates that caution and regular review are appropriate The score per se should not be used to exclude patients from anti-coagulation Need to address the correctable risk factors for bleeding

32 Cynthia Davies Bleeding Risk: HAS-BLED Score H Hypertension 1 A Abnormal renal and liver function* 1 or 2 S Stroke 1 B Bleeding 1 L Labile INRs 1 E Elderly >65years 1 D Drugs eg aspirin, NSAID, alcohol* 1 or 2 *1 point each. A Score >=3 indicates high risk Therefore, caution required with either anti-platelet or oral anticoagulant therapy

33 HAS-BLED score 1 NICE: anticoagulant options decision aid

34 Definitions for HASBLED SCORE HYPERTENSION SYSTOLIC BP >160 mmhg Abnormal Kidney function chronic dialysis or renal transplantation or serum creatinine > 220umol Abnormal liver function chronic hepatic disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement (e.g. bilirubin > 2 x upper limit of normal, in association with aspartate amionotransferase/alanine aminotransferase/alkaline phosphatise > 3x upper limit of normal, etc) Bleeding previous bleeding history Labile INR s - poor time in therapeutic range (e.g. <60%) Drugs/alcohol use concomitant use of drugs such as antiplatelets, nsaids or alcohol abuse

35 Mrs Cynthia Davies She was started on Warfarin but despite good concordance her INR s have been very erratic.

36 Poor anticoagulation control 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months 2 INR values less than 1.5 within the past 6 months Time in treatment range less than 65% Atrial fibrillation: the management of atrial fibrillation NICE clinical guideline 180 NICE All rights reserved. Last modified June 2014 Page 16 of 49

37 Address factors that may contribute to poor INR control: cognitive function adherence to prescribed therapy illness interacting drug therapy lifestyle factors including diet and alcohol consumption

38 Non vitamin K Oral Anti-Coagulants (NOAC s) (Dabigatran, Rivaroxaban and Apixaban) At least as effective as Warfarin Lower risk of intracranial haemorrhage Higher risk of GI bleeding (Dabigatran and Rivaroxaban) Rapid onset/short half-life Renal function issues Do not need to monitor INR Do need to monitor (see next slide) Not for patients with Valvular AF or those with prosthetic heart valves

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40 Mrs Cynthia Davies 80* year old & Weight: 59Kg* Estimated Creatinine Clearance: 61.6 ml/min (mdcalc.com/ebnf) Changed from Warfarin to Apixaban 2.5mg twice daily (*thus lower dose) Managing well with her new regime and booked in for follow-up monitoring with GP

41 Those on anti-arrhythmic drugs should be reviewed regularly (at least annually) ESC, 2012

42 Monitoring Patients with Atrial Fibrillation Renal function/potassium levels Rhythm/Rate Control (ECG) Underlying cardiovascular issues Digoxin toxicity Other anti-arrhythmic monitoring (e.g. Amiodarone, Dronedarone) Signs of deterioration/heart failure Anticoagulation: risk v benefit changes with time

43 Audit suggestions High Risk - CHA 2 DS 2 VASc >2 not on anticoagulation including those on antiplatelet; review if suitable for warfarin/noac Moderate risk CHA 2 DS 2 VASc =1 male only, not currently on anticoagulation; consider warfarin/noac Low risk CHA 2 DS 2 VASc = 0; review reason if on anticoagulant or antiplatelet drug Also All people on antiplatelet AND anticoagulation, should both be continued? Those on anti-arrhythmic drugs such as Amiodarone regular review indicated

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45 How to order All our resources are free to order, although we do ask for a donation if you can afford one Web: bhf.org.uk/publications Call: orderline@bhf.org.uk

46 Heart helpline For patients and staff

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49 Type of medication Common Side-effects Monitor Beta-Blocker (that is, a beta-blocker other than sotalol) Bronchospasm (thus contraindicated with asthma) Bradycardia, hypotension Fatigue Cold extremities sleep disturbance with nightmares Symptoms, blood pressure, heart rate and renal function. Diltiazem (Rate-limiting calcium antagonist) (Unlicensed indication) Digoxin (Non-paroxysmal AF only) Bradycardia palpitation, dizziness, hypotension, malaise, asthenia, headache, hot flushes, gastro-intestinal disturbances, oedema (notably of ankles); Nausea, vomiting, diarrhoea; arrhythmias, dizziness; blurred or yellow vision; rash, eosinophilia Symptoms, blood pressure and heart rate Symptoms In renal impairment reduce dose and monitor plasma-digoxin concentration; toxicity increased by electrolyte disturbances If experiencing side-effects check a venous digoxin level to check for DIGOXIN TOXICITY Adapted from NICE, 2014 and ebnf July 2015, downloaded Refer to BNF for full contraindication, dosage and side-effect information

50 References All Parliamentary group on atrial fibrillation/aha (2013) A guide to AF within the Cardiovascular Disease Outcomes Strategy. A_Guide_to_AF_within_the_Cardiovascular_Disease_Outcomes_Strategy.pdf last downloaded Camm AJ, Kirchhof P, Lip GY et al (2010) Guidelines for the management of atrial fibrillation. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology. Eur Heart J 31(19): doi: Camm AJ, Lip GY, De Caterina R et al (2012) 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 33(21): doi: /eurheartj/ehs253. GPN Article (2015) tbc ebnf July 2015, downloaded National Institute for Health and Care Excellence (NICE) (2011) Guidance CG 127: Hypertension: Clinical management of primary hypertension in adults. August National Institute for Health and Care Excellence (NICE), National Clinical Guideline Centre (2014) Atrial Fibrillation: the management of atrial fibrillation. Clinical guideline 180. Methods, evidence and recommendations. June Commissioned by the National Institute for Health and Care Excellence (full version and key recommendations). O Riordan M (2014) No Benefit and More Bleeds with Antiplatelet for AF Patients with Stable CAD. (accessed 19 November 2014). UKMi (2015) Common Questions and Answers on the Practical Use of Oral Anticoagulants in Non- Valvular Atrial Fibrillation- South West Medicines Information and Training and Regional Drug and Therapeutics Centre (Newcastle) version March last downloaded