Atrial Fibrillation revisited by PACE

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Atrial Fibrillation revisited by
PACE

• Primary Care Management

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Why do women have two hands?
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And why do men have two hands?
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Whats coming up?

• Some facts about Atrial Fibrillation
• Classification
• Treatment Strategies
• Thromboprophlaxis
• When to refer
• Screening
• Summary

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Prevalence

• Commonest sustained cardiac arrhythmia
• Prevalence doubles with each advancing decade
• 0.5 at age 50-59 to almost 9 at age 80-90
• More common in older males
• Aging population increases disease burden

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Causes of Atrial Fibrillation

• Hypertension
• Myocardial infarction
• Heart failure
• Valve disease
• Congenital heart disease
• Cardiomyopathies / Pericardial disease
• Pre-excitation syndromes
• Lone AF

• Respiratory illnesses
• Diabetes
• Thyroid disease
• Acute infections / sepsis
• Electrolyte depletion
• Drugs/Alcohol
• Postoperative
• Familial AF

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Complications and Prognosis

• 5-fold increase in risk of stroke and
  thromboembolism
• Strokes associated with AF are more severe
• Death OR 1.5 1.9
• AF worsens diagnosis in CHD and HF
• Impairment in cognitive function
• Reduced exercise tolerance

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Investigations

• ECG is mandatory
• Serum urea and electrolytes and thyroid function
• ECHO?
• Ambulatory rhythm monitoring

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Echocardiography

• 1.1.3.1 In patients with AF, transthoracic
  echocardiography (TTE) should be performed in
• those in whom a baseline echocardiogram is
  important for long-term management, such as
  younger patients D(GPP)
• those being considered for a rhythm control
  strategy including cardioversion (electrical or
  pharmacological) C
• those in whom there is a high risk or a
  suspicion of underlying structural/functional
  heart disease (such as heart failure, heart
  murmur) that influences their subsequent
  management (such as choice of antiarrhythmic
  drug) D(GPP)
• those in whom refinement of clinical risk
  stratification for antithrombotic therapy is
  needed (see section 1.8.6). C
• 1.1.3.2 In patients with AF in whom the need to
  initiate anticoagulation therapy has already been
  agreed on appropriate clinical criteria (see
  section 1.8.6) transthoracic echocardiography
  should not be routinely performed solely for the
  purpose of further stroke risk stratification.

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Classification of Atrial fibrillation
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Rate vs Rhythm control

• None of the six RCTs found rate control inferior
  in terms of mortality or quality of life
• One study showed rate control reduced the
  mortality in patients without HF, in over 65s and
  in patients with CHD
• Reduced rates of hospitalisation and adverse
  events with rate control
• No difference in the rate of thromboembolic or
  haemorrhagic events
• Rate control is more cost effective.

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For rate control For rhythm control

• Patients over 65
• Patients with coronary heart disease
• Patients unsuitable for cardioversion
• Patients with contraindications to antiarrhythmic
  drugs

• Presenting for the first time with lone AF
• Younger patients
• Patients with Congestive heart failure
• Symptomatic patients
• Patients with AF secondary to a treated/corrected
  precipitant

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How to achieve rate control?
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Rhythm control for paroxysmal AF

• Remove precipitant
• Do nothing
• Beta-blocker
• Refer
• Pill-in-pocket

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Rhythm control strategy for persistent AF

• 1. Cardioversion
• 2. Beta-blocker
• 3. Treatment failure reconsider treatment
  strategy
• 4. Class Ic or III antiarrhythmic drugs

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Thromboembolic prophylaxis

• Thromboembolic events do not just just occur in
  permanent AF
• Consider treatment for all patients with AF
• Clustering of events at the time of onset
• 62 RR reduction with adjusted dose Warfarin
• 22 RR reduction with Aspirin
• 0.9 absolute risk increase of major haemorrhage
  with Warfarin

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Risk assessment tools

• Do not apply to valvular heart disease
• Risk of thromboembolism depends on other risk
  factors in patients with AF
• Various risk assessment tools available
• There are differences between CHAD2 and the tool
  favoured in the NICE guidelines

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When to refer?

• Patient aged below 30
• AF resistant to usual drugs for rate control
• Patient suitable for rhythm control requiring
  cardioversion
• Uncontrolled paroxysmal AF on usual medication
• Syncope related to AF
• Patient with moderate-severe HF
• murmur in a patient with AF
• AF with broad ventricular complexes

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Key messages

• All patients with AF need thromboembolic risk
  assessment
• Rate control will benefit most of your patients
• Digoxin is not first line drug for rate control
• Beta-blocker is first line drug for rhythm
  control
• Manual pulse palpation is an effective screening
  tool.

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