AF Diagnosis Incpated into over 75 health checks and Public Health Checks Pulse Feel the pulse in all >65yrs If irregular do a 12 Lead ECG with Rhythm strip Check Thyroid and FBC and heart rate Refer to cardiology if: Young (under 50, consider older patients if wrying symptoms) Patient is symptomatic (Consider acute medical admission) -Chest Pain -Heart Failure -Palpitation heart rate > 140 -Shtness of Breath -Ankle Swelling -Dizziness SBP < 100 If AF co-exists with -Ischaemic heart disease -Heart failure -Known valular heart disease If Rhythm control is required Paroxysmal AF is present Wolff-Parkinson-White is present In the absence of any of the above commence treatment: Anticoagulant after undertaking a CHA2DS2-VASc sce and HAS-BLED sce Rate control
Anticoagulation in Non-Valular AF CHA2DS2 - VASc http://www.mdcalc.com/cha2ds2-vasc-sce-f-atrial-fibrillation-stroke-risk/ f atrial fibrillation stroke risk Age <65 0 65-74 +1 75 +2 Sex Male 0 Female +1 Conditions Congestive Heart Failure histy +1 Hypertension histy +1 Stroke/TIA/Thromboembolism histy +2 Vascular Disease histy +1 Diabetes Mellitus histy +1 If sce is 1 me consider Anticoagulation Contra-indications to anticoagulation Active bleeding Significant risk of maj bleeding e.g. o Recent gastro-intestinal ulcer o Oesophageal varices o Recent brain, spine ophthalmic surgery o Recent intracranial haemrhage o Malignant neoplasms o Vascular aneurysm
HAS-BLED bleeding Risk HAS-BLED http://www.mdcalc.com/has-bled-sce-f-maj-bleeding-risk/ Clinical characteristic Points awarded Hypertension (uncontrolled > 160 mmhg systolic) 1 Renal impairment (including dialysis transplant) 1 2 Liver impairment 1 Stroke Histy Bleeding (Histy of predisposition to) 1 Labile INRs (time in therapeutic range < 60%) 1 Elderly (age >65 years) 1 Medication predisposed to bleeding (antiplatelets, NSAIDs) 1 Drug alcohol ( 8 drinks\week)(1 point each) 1 2 HAS-BLED sce 1 Risk is 3.4% 1.02 bleeds per 2 Risk is 4.2% 1.88 bleeds per 3 Risk is 5.8% 3.72 bleeds per 4 Risk is 8.9% 8.70 bleeds per 5 Risk is 9.1% 12.50 bleeds per 6 s greater than 5 are considered too rare to risk assess Anticoagulation should be considered. Patient has a relatively low risk f maj bleeding (1/s) Anticoagulation should be considered. However, the patient has a moderate risk f maj bleeding (2/s) is at high risk f maj bleeding
Anticoagulation Treatment CHA2DS2 VASc sce of 1 me + HASBLED sce less than 3 Initiate Warfarin Target INR 2.5 If Warfarin is contraindicated Patient is unable to manage variable dosing Initiate Apixaban (check contra-indications) INR stable Continue warfarin If the INR is outside target range on 2 occasions in a six month period Over 8 on one occasion and no identified reason STOP The patients on-going need f anticoagulation should be check every 6 months
Rate Control Initiate Bisoprolol 5mg-10mg daily, 10mg daily maximum dose Initiate slowly if patient also has heart failure: 1.25mg daily f one week 2.5mg daily f one week 3.75mg daily f one week 5mg daily f one week 7.5mg daily f one week 10mg daily f to continue Atenolol 50mg-100mg daily If beta-blocker not tolerated contraindicated consider Calcium blocker Diltiazem (Prescribe by brand Slozem once daily 120mg-240mg once daily, increasing to 360mg daily if necessary) Review in 2 weeks, then every 2/52 until rate <100bpm Allow 4-6/52 f each drug to wk Although routinely used bisoprolol, atenolol and diltiazem are not licensed f the treatment of AF f, patients should be started at the lowest dose and titrated upwards every 2-4 weeks