Atrial Fibrillation Cases. Dr Paul Broadhurst Consultant Cardiologist

Atrial Fibrillation Cases Dr Paul Broadhurst Consultant Cardiologist November 2011

Mr TH age 72 Routine medical for hypertension check Denies any symptoms despite close questioning PMH: hypertension, MI, TIA last year DH: atenolol 50, ramipril, aspirin, statin Irregular pulse 72bpm, no murmurs, BP 125/ 80

Atrial fibrillation with slow VR

Flutter waves

AF with VVI pacing

Mr TH age 72 Routine medical for hypertension check Denies any symptoms despite close questioning PMH: hypertension, MI, TIA last year DH: atenolol 50, ramipril, aspirin, statin AF with VR 72bpm(ECG), no murmurs, BP 125/ 80

Management Strategy Reduce risk thromboembolic underlying heart disease/contributing factors Rate versus rhythm

Investigations in primary care ECG, particularly during arrhythmia FBC/U&Es/LFTs/Glucose/TFTs Lipids if CAD suspected INR if to go on to warfarin Echo (if rate controlled) may not be necessary if patient to be referred Occasionally Holter/ETT

Reduce risk Manage underlying condition Eg hypertension, impaired LV function, thyrotoxicosis, alcohol excess etc

Reduce risk Consider anticoagulation Not required in low risk patients/acute AF Balance risk vs benefit of antithrombotic Px Tornoczky, T. et al. N Engl J Med 2004;351:e25

Cautions/Contraindications to warfarin Significant bleeding risk GI/GU or other bleeding in the last 6/12 previous intracerebral bleed or recent suspected stroke alcohol abuse inability/unwillingness to comply with Px/monitoring recurrent falls uncontrolled hypertension (>180/110) liver disease pregnancy

Cautions/Contraindications to aspirin Aspirin allergy GI bleeding (<6/12) active proven peptic ulcer BP>180/110 Consider PPI or clopidogrel (or nothing! ) instead

Atrial Fibrillation NICE clinical guideline 36, Issue date June 2006

Atrial Fibrillation NICE clinical guideline 36, Issue date June 2006

Rate control in chronic AF - Improve symptoms, prevent/treat CM 1) Digoxin (occasionally in the elderly) 2) beta-blockers 3) verapamil or diltiazem or combinations of above caution with 2 + 3 don t use amiodarone to control rate alone

Rate control Controlled ventricular rate <80/min at rest if symptomatic, 100 if asymptomatic Holter monitoring/exercise testing If drug refractory, symptomatic and no aggravating factors eg uncontrolled heart failure, thyrotoxicosis etc consider pace and ablate (or rhythm control) strategy VVIR pacemaker (sometimes DDDR,?biventricular in the future) followed by catheter ablation of AV-node

Mr TH age 72 Routine medical for hypertension check Denies any symptoms despite close questioning PMH: hypertension, MI, TIA last year DH: atenolol 50, ramipril, aspirin, statin AF with VR 62bpm(ECG), no murmurs, BP 125/ 80 Start warfarin continue rate control strategy Arrange echo, TFTs No need to refer

Echo: LA 4.5cm, mild LVH Normal bloods Established on warfarin

Established on warfarin INR 2-3 March 2011 May 6 INR 2.9 (2mg) June 1 INR 3.4 June 8 INR 3.7 (1mg) June 15 INR 1.8 (1-2mg) June 22 INR 2.3 July 3 INR 1.9 (1-2- 2mg) July 10 INR 2.9 July 31 INR 4.5 (1mg August 6 INR 2.2 August 13 INR 1.5 (1-2mg August 20 INR 1.9 August 27 INR 1.8 Sept 4 INR 1.9

What next?

What next? Patients will be considered for dabigatran over warfarin where warfarin cannot be administered safely or effectively eg time in target INR range<60% patients have had a major bleed solely due to a high INR on warfarin patients are allergic or intolerant of warfarin or the drug is contraindicated patients with AF who have experienced an ischaemic stroke despite therapeutic levels of anticoagulation whilst taking warfarin may be considered for dabigatran, by a senior stroke physician, as may occasional patients in whom the use of warfarin proves logistically difficult due to an inability to access medical services.

Ms JA age 32 Presented with mild palpitations and effort dyspnoea for last 8 days No prior history. No HBP. moderate alcohol, smokes. In AF clinically 140bpm, no murmurs, no HF. BP 110/59 What next investigations/management/referral?

Atrial Fibrillation NICE clinical guideline 36, Issue date June 2006

Rhythm control - persistent AF If acute and highly symptomatic, admit duration <48 hours, cardiovert with drugs eg flecainide or DCCV duration >48 hours, anticoagulate with warfarin, aiming for INR >2 for 1/12, control rate if necessary then DCCV (occasionally precardioversion warfarin is omitted in an emergency, when TOE is usually performed to exclude LA thrombus) Continue warfarin for at least 1/12 post cardioversion, longer if risk of (and from) relapse significant (AFFIRM)

Antiarrhythmic drugs First episode of AF in whom risk of recurrence is high (1 year relapse rate ~ 70%) Recurrent, persistent AF in whom rhythm control approach is desired Paroxysmal AF

Antiarrhythmic drugs Beta-blocker - safest Sotalol Class 1C (and occasionally 1A) drugs Dronaderone Amiodarone - most effective and toxic (70% in SR at 1 year) All of the above can be proarrhythmic eg bradycardia, torsades, monomorphic VT, atrial flutter, SCD

Ms JA age 32 Presented with mild palpitations and effort dyspnoea for last 8 days No prior history. No HBP. moderate alcohol, smokes. In AF clinically 140bpm, no murmurs, no HF. BP 110/59 What next investigations/management/referral? ECG, TFTs (exclude pre-excited AF if it is then admit) Betablocker then perhaps echo Warfarin could be started as restoration of SR will be the aim Refer to cardiology (assuming TFTs OK!) See back in few days to ensure decent rate control and? have they cardioverted

Mr PB age 40ish 3 rd episode of significant PAF in last 3 mths lasts 12 hours or so, often gets brief episodes Palpitations, feels washed out Has been on regular betablocker and aspirin for 12 months No other significant hx.. Normal echo, normal TFTs, no RF for IHD Now back to SR What is next therapeutic step? Does he require warfarin? Refer to cardiology Class Ic agent eg flecainide under hospital supervision? Candidate for electrophysiologist referral

Rhythm-control for paroxysmal AF (and persistent) Atrial Fibrillation NICE clinical guideline 36, Issue date June 2006

Current evidence on the safety & efficacy of percutaneous RFA for AF appears adequate to support the use of this procedure in appropriately selected patients... Percutaneous RFA for AF NICE Interventional Procedure Guidance 168 Issue date April 2006

When to refer to a cardiologist Younger patients Desire to use rhythm control drugs or strategies Continuing symptoms

Mr RG age 78 Fatigue, dyspnoea mild exertion last 3/12, now orthopnoea Hypertension nil else In AF, VR 115bpm, basal creps, mild odema BP 140/ 80 DH: atenolol 50mgbd, ramipril, aspirin, statin ECG confirms AF plus LVH, routine bloods What next? Warfarin or not? Rate or rhythm control? Echo will help decision: LVH with good systolic function Add digoxin reasonable but if rhythm control strategy adopted amiodarone (or dronaderone) would be better later Refer to cardiology if for rhythm control or if symptomatic/inadequate rate control despite digoxin

Mrs XYZ age 55 Increased dyspnoea last few months Known severely impaired LV due to DCM on ramipril 10mg, carvedilol 25bd, frusemide 40mg, aspirin Diabetic on insulin OE: AF VR 100bpm, no clinical HF ECG: confirms AF Warfarin or not? Rate or rhythm control? If rate add digoxin (or increase carvedilol if submaximal) If rhythm add amiodarone and plan to continue it longterm following DCCV warfarin lifelong regardless if SR maintained

Summary Make an accurate diagnosis Consider either rate or rhythm control strategy Influenced by patients symptoms, age, underlying heart disease and wishes Minimise risk and treat underlying cause