atrial fibrillation- an introduction - heart group nurses/sara... · introduction atrial...
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Atrial Fibrillation (AF)-an introduction
Sara Dando
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Introduction
Atrial Fibrillation- an overview
Mechanisms of AF
Risk factors
ECG
Management
Anticoagulation and stroke risk
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Atrial Fibrillation
1-2% of the population are affected by AF and it's
prevelance increases with age
Men are more frequently affected than women
Increased incidences of death, thrombo-embolic events,
stroke, decreased exercise tolerance, reduced quality of life,
heart failure and left ventricular dysfunction
AF may remain undiagnosed for significant periods (silent
AF)
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Mechanisms
Atrial cells fire at 400-600 times per minute.
The AV node acts as a frequency filter preventing
excessive ventricular rates
Cardiac output can be reduced by 5-15% due to acute loss
of coordinated atrial mechanical function
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Risk Factors
Systolic and diastolic heart failure
Valvular heart disease
Myocardial infarction
Hypertension
Diabetes
Obesity
Cigarette smoking
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Clinical manifestations
(May or may not include)
Palpatations
Decreased exercise tolerance
Fatigue
Shortness of breath
Chest discomfort
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Types of Atrial Fibrillation
First diagnosed AF
Paroxysmal AF
Persistent AF
Long-standing persistent AF
Permanent AF
Silent AF
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Detection
12 lead ECG
Holter monitoring
Event monitoring
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Definition
ECG has'absolutely' irregular RR intervals
No distinct P waves seen on the ECG
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ECG
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Atrial Flutter
Atrial flutter is unlike AF, it results from a circuit usually in
the right atrium.
The management is different from atrial fibrillation and
ablation is often a good treatment option
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Figure 2. Atrial flutter results from a rapid circuit that occurs most commonly in the right atrium.
Boyer M , and Koplan B A Circulation 2005;112:e334-e336
Copyright © American Heart Association
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ECG
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Long term management of Atrial Fibrillation
Prevention of thromboembolism
Symptom relief
Optimal management of contributing cardiovascular
disease
Protect the LV from the effects of tachycardia
Correction of rhythm disturbance.
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Rhythm versus rate control
Rhythm control - restore and maintain sinus rhythm
Rate control - leaves the patient in AF while targeting ventricular rate response
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Pharmacological rate control
Conventional beta blockers such as Metoprolol
Calcium channel antagonists such as diltiazem
Digoxin
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Rhythm control
Antiarrhythmic drugs such as sotalol, flecanide, amiodorone
Direct current cardioversion
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Assessing Stroke Risk
5% /year is the average risk of stroke in patients with AF
this increases to 20% with mitral stenosis and AF
The risk of AF complications is not different between short
episodes versus sustained episodes
The dominant source of embolism, >90% in non valvular
AF, is the left atrial appendage
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Risk factor-based point-based scoring system - CHA2DS2-VASc
*Prior myocardial infarction, peripheral artery disease, aortic plaque.
Actual rates of stroke in contemporary cohorts may vary from these estimates
European Heart Journal (2010) 31, 2369-2429
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The HAS-BLED bleeding risk score
*Hypertension is defined as systolic blood pressure > 160 mmHg
INR = international normalized ratio
European Heart Journal (2010) 31, 2369-2429
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Anticoagulation
Dabigatran (Pradaxa)
(Exclude patients with severe renal impairement,Createnine clearence
<30ml/min)
Dose- Adults 150 mg twice daily
80 years and above 110 mg twice daily
Warfain
Once daily dose according to INR
Maintain INR between 2-3 with a target of 2.5
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Take Home Message
If you have an irregular pulse
Think about AF
Take an ECG
Then assess for stroke risk.
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ReferencesCamm, A., Kirchhof, P., Lip, G., Schotten, U., Savelieva, I., Ernst, S., Van Gelder, I., Al-Attar, N., Hindricks, G., Prendergast, B., Heidbuchel, H., Alfieri, O., Angelini, A., Atar, D., Colonna, P., De Caterina, R., De Sutter, J., Goette, A., Gorenek, B.,Heldal, M., Hohloser, S., Kolh, P., Le Heuzey, J-Y., Ponikowski, P., Rutten, F.(2010).Guidelines for the management of atrial fibrillation. European Heart Journal, 31, 2369-2429.doi:10.1093/eurheartj/ehq278
Connolly, S., Ezekowitz,M., Yusef,S., Eikelboom, J., Oldgren,J., Parekh, A., Pogue,J., Reilly, P., Themeles, E., Varrone, J., Wang, S., Ailings, M., Xavier, D., Zhu, J.,Diaz, R.,Lewis, B., Darius, H.,Diener, H-C., Joyner, C., Wallentin, L., and the RE-LY Sterring committee and Investigators, (2009). Dabigatran versus warfarin in patients with Atrial Fibrillation. N Engl J Med , 361:1139-1151 DOI: 10.1056/NEJMoa0905561
Mims New Ethicals
New Zealand Datasheet- Dabigatran etexilate
Wadke, R.(2013). Atrial fibrillation. Disease-a-Month, 59, 67-73. http://dx.doi.org/10.1016/j.disamonth.2012.12.002
New Zealand Guidelines Group (2005). The Management of People with Atrial Fibrillation and Flutter. www.nzgg.org.nz