af clinical approach - workshop

ATRIAL FIBRILLATION

CLINICAL APPROACH

AF WORKSHOP 2014

PRINCIPLES OF AF MANAGEMENT

(1) Rate control.

(2) Prevention of thromboembolism.

(3) Optimal management of etiology

concomitant disease & complications.

(4) Symptom relief.

(5) Correction of rhythm disturbance.

CLINICAL APPROACH

CLINICAL HISTORY

EXAMINATION

RELEVANT INVESTIGATION

DEFINE TYPE OF AF

STRATIFY FOR STROKE PREVENTION

STRATIFY BLEEDING RISK

CONTROL RATE

TREAT CAUSES/COMPLICATIONS

IDENTIFY & CLOSE MONITOR HIGH RISK PT

CLINICAL HISTORY

Acutely unwell : unstable

Symptomatic :

- Dyspnoea

- Palpitation

- Lethargy

- Dizziness

- Syncope

- Chest pain/discomfort

Associated condition or

complications :

- Heart failure,

- ACS

- Thyrotoxicosis,

- Stroke

- SA node dysfunction

Opportunistic :

- Asymptomatic

- Incidental

- Non specific symptoms

STRATIFY SYMPTOMS

PHYSICAL EXAMINATION

BP, HR : manual,pulse check

CVS/RESP/CNS/THYROID etc

RELEVANT INVESTIGATIONS

12 lead ECG : confirm diagnosis & rate

TRANSTHORACIC ECHOCARDIOGRAPHY

- valvular vs non valvular vs structural lesion

- LV function, LA size

- intramural clot

- LVH etc

RFT/LFT/FBS/RBS/COAGULATION/TFT /LIPIDS

etc

CXR

DEFINE TYPE OF AF

VALVULAR AF :

- valvular

- rheumatic heart

disease

- prosthetic valves

NON VALVULAR AF

STRATIFY FOR STROKE PREVENTION

VALVULAR AF

- ANTICOAGULANT

NON VALVULAR AF

DO CHADS2 or CHA2DS2VASc score

- ANTICOAGULANT

or

- ANTIPLATELET

or

- NONE

CHADS2 SCORE ANTITHROMBOTIC THERAPY

0 → ASPIRIN OR none

1 → ORAL ANTICOAGULANT or aspirin

≥ 2 → ORAL ANTICOAGULANT

* Heart failure or LVEF ≤ 40%

*

CHA2DS2-VASc SCORE

CHA2DS2-VASc score antithrombotic therapy

0 → none or aspirin

1 → oral anticoagulant or aspirin

≥ 2 → oral anticoagulant

Vascular disease : MI, PVD, Aortic plaque * LVEF ≤ 40%

*

WHICH SCORING SYSTEM ?????

CHADSVASc – provides a more accurate estimation of risk

THE BEST APPROACH……

DO CHA2DS2-VASc SCORE

FROM THE START

DO CHADS2 SCORE FIRST

IF SCORE : 0 OR 1

DO CHA2DS2-VASc SCORE

STRATIFY BLEEDING RISK- HAS-BLED SCORE

≥ 3points: HIGH RISK

CONTROL RATE

PRIORITY FIRST IS RATE CONTROL

PERSISTENT & PERMANENT AF- RATE CONTROL

PAROXYSMAL AF - NO RX

- RATE CONTROL

- RHYTHM CONTROL

CHOOSE BEST DRUG

SET VENTRICULAR RESPONSE RATE

TREAT

REVERSIBLE CAUSES

UNDERLYING PERPETUATING CONDITION

COMPLICATIONS

ASSOCIATED CONDITIONS

IDENTIFY & CLOSE MONITOR HIGH RISK PT

Clinical Hx, Examination

↓

ECG, Echo, CXR, bloods – TFT, RFT,LFT,LIPIDS, FBS etc

↓

Define- type of AF

↓

Stratify : - risk of stroke ( valvular or CHADS2 or CHA2DS2VASc score )

- risk of bleeding (HAS-BLED score )

↓

RX- Rate control first & anticoagulant as indicated

↓

Treat causes, ppt , complications , asstd conditions

↓

Identify & close monitor high risk pt

APPROACH IN STABLE , ASYMPTOMATIC / MINIMAL SYMPTOMS AF

Clinical Hx, Examination

↓

ECG, Echo, CXR, bloods – TFT, RFT,LFT,LIPIDS, FBS etc

↓

Define- type of AF

↓ RX- Rate control first & complications

↓

Stratify : - risk of stroke (valvular or CHADS2 or CHA2DS2VASc score )

- risk of bleeding (HAS-BLED score )

↓

RX- anticoagulant as indicated

↓

Treat causes, ppt , asstd conditions

↓

Identify & close monitor high risk pt

APPROACH IN STABLE , SYMPTOMATIC AF

Quick : Clinical Hx, Examination

↓

RX- Cardioversion & IV heparin / LMWH

↓

ECG, Echo, CXR, bloods – TFT, RFT,LFT,LIPIDS, FBS etc

↓

Define- type of AF

↓

Stratify : - risk of stroke (valvular or CHADS2 or CHA2DS2VASc score )

- risk of bleeding (HAS-BLED score )

↓

RX- anticoagulant ,rate or rhythm control as indicated

↓

Treat causes, ppt , complications , asstd conditions

↓

Identify & close monitor high risk pt

APPROACH IN UNSTABLE AF