The Atrial Fibrillation Clinic in Llanelli. Dr Lena Marie Izzat Consultant Cardiovascular Physician

Transcription

1 The Atrial Fibrillation Clinic in Llanelli Dr Lena Marie Izzat Consultant Cardiovascular Physician

2 Llanelli Multidisciplinary AF Clinic Went live January 2009 Based on the fact that Carmarthenshire has one of the highest levels of AF prevalence in the UK and highest in Wales! Invitations sent to Carmarthenshire catchment area GP s Open to all physicians, A&E department, CSNs and surgical pre-assessment clinics.

3 Who is Referred? Newly diagnosed atrial fibrillation where cardiology advice is deemed suitable. GPs encouraged to contact us by phone or fax to decide on telephone advice or clinic review Patients with established diagnosis who require specialist input ( All PAF or Chronic symptomatic AF with poor rate control)

4 Required Assessment prior to Clinic Referral from GP Brief clinical and treatment history Physical examination. ECG essential. FBC / U&E / glucose/ TFT Optional referral for open access echocardiography

5 Aims of the Clinic One-Stop Shop The clinic aims to support our local surgeries in looking after patients with atrial fibrillation Based on the fact that the majority of AF can be managed safely In primary care Serves to conduct an initial assessment and highlight a comprehensive and detailed management framework for the referrer Majority of patients require 1-2 visits Patients leave with: a clear classification of AF type a succinct management plan including stroke risk management commenced on the day!

6 At the Clinic CV Risk Factor Assessment (Q Risk) Physical Examination / ECG CHADS 2 score CHA2DS2 vasc Score Referral to anticoagulant clinic if appropriate Referral for Echo if appropriate Management plan and decision on rhythm control or rate control strategy Tertiary centre referral for nonpharmacological management if appropriate Other CV tests arranged if needed (ETT / CAG)

7 AF Data Sample 2009 to date Forms received for 435 patients however 57 patients excluded as not in AF so total number included = 378 patients

8 Referral Source A&E = 2 HF Nurse = 2 Cardiac Nurse = 5 Cardiology clinic = 34 Cardiology post cardioversion = 8 Con Physician = 118 GP = 194 Med Registrar = 2 Medical Admission Unit = 2 Not Doc = 4 Medical Nurse =1 Surgical OPD = 1 Pre-assessment = 11 Valve clinic = 1

9 Gender Male Female 121, 32% 257, 68% N=378

10 Age Mean average age = 67 years < N=378

11 CHADS2 Score 82% CHADS0-2 35% 28% 19.5% 10% 5% N=378

12 Diagnosis 44% 35% 21%

13 Decision 52% 48%

14 Referred for Anti-coagulation

15 Referred for Echo

16 Cardioversion

17 DC Cardioversion Cardioversion patients closely monitored by a number of dedicated CCU staff with an interest and booked in as soon as INR levels at target Dedicated area and anaesthetic input for DC cardioversion lists 2 X/ month Up to 4 patients treated each list All patients seen and managed by the consultant on the day of the procedure Follow-up at 6-8 weeks in nurse-led AF clinic

18 Conclusions Team effort involving physicians, CSNs, cardiac technicians, anaesthetists and anticoagulant service. Patients assessed promptly and thoroughly Investigations and anticoagulation decided and often initiated as one-stop. Seamless transfer between departments. Referral to tertiary centre for AF ablation in suitable patients when applicable. Classed as an example of best practice in Wales, we have been honoured by the AFA and Government as healthcare pioneers

19 Cases from the clinic!

20 Mr CH 76 Admitted to WWGH June 09 with sudden onset fast AF. PMHx: BP / CHA2DS2vasc: 3 ( BP + age) Treated with beta-blockers / No DC version, not keen on procedure Referred to us in March/10: SOB and lethargy / HR: 110 AF Echo: Good LV/ LA size 4.2cm but elongated DC version April 10 initially successful

21 July 10: Back in AF / HR 140 BPM on Warfarin and Bisoprolol 5mg o.d and feels unwell again and unhappy to continue warfarin! What are the options?

22 Mr TD 45 CHA2DS2vasc: 1 Admitted June 09 : SOB (NYHA III-IV), leg oedema and palpitations. Found to be in AF / HR 130BPM in LVF ECHO: Poor LV / EF <35% / DCM Rx: ACEI, Beta-blocker, diuretic, spironolactone, warfarin CAG: Normal coronaries 4/12: LV back to normal DC version : Failed

23 TD Upset, wants another attempt at DC version. New DC version with amiodarone pre-treatment / successful for 4/52 but cannot tolerate amiodarone! Back in AF / excellent rate control on Bisoprolol 10mg and Digoxin 125 mcg but insists on rhythm control strategy. Referred to London / not suitable for CPVA but referred for open MAZE! Maintained SR for 48 hours! Back in AF : What next?

24 Mrs JT 60 CHA2DS2vasc: 2 Admitted May 05: Atypical CP / PAF reverted to SR spontaneously. PMHx: Hypertension / Asthma Rx: ASA, Amlodipine, Sotalol 40mg b.d and seretide!! Readmitted July 05: Further admission with PAF but wheezy! Sotalol stopped and Flecainide commenced but awful SE so stopped subsequently. Readmitted June 06 in persistent AF, Digoxin and warfarin commenced and DC version planned. Echo: Normal

25 CHA2DS2vasc 4 JT August 06 / TIA / CT and Carotid doppler normal / INR: 1.9! May 07 DC version: NSR, discharged on Tildiem, ACE I, Warfarin and seretide. Back in AF April 09 / Repeat Echo normal. Further TIA June 09 / INR 1.8! Very symptomatic despite HR of 80 AF! Further DC version with Amiodarone since Nov 09, still in SR but still on Amiodarone! What next?

26 Thank you