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AF: Diagnosis & treatment @LWNurses #LearnWithNurses #LWN Michaela Nuttall RGN MSc Founder, Learn With Nurses Director, Smart Health Solutions Clinical Advisor for CVD Prevention, Public Health England Associate in Nursing, C3 Collaborating for Health Chair, Health Care Committee HEART UK Member, Nurses Working Party and Guidelines & Information Working Party, British and Irish Hypertension Society Trustee, PoTS UK and Bromley Third Sector Enterprise @ thisismichaelaUsing Medall.orgClosed FB group & Page AF across the world • A total of 3.046 million new cases of atrial fibrillation worldwide were registered during 2017. • The estimated incidence rate for 2017 (403/millions inhabitants) was 31% higher than the corresponding incidence in 1997. • The worldwide prevalence of atrial fibrillation is 37,574 million cases (0.51% of worldwide population), increased also by 33% during the last 20 years. The highest burden is seen in countries with high socio-demographic index, though the largest recent increased occurred in middle socio-demographic index countries. • Future projections suggest that absolute atrial fibrillation burden may increase by >60% in 2050. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge, 2020 The devastation of AF related strokes • FIVE times more likely to have a stroke • TWICE as likely to die prematurely • Half of those with AF related stroke will not survive beyond 12 months • Those that do will suffer increased disability compared to those who suffer non AF related strokes Impacts on health and wellbeing • Heart failure: 20-30% of all AF patients have LV dysfunction • Hospitalizations- 10-40% of AF patients are hospitalised every year • Cognitive decline and vascular dementia; more common in those with AF than those without • Decreased quality of Life and depression; more common in those with AFWe have to look for it…Or it finds us The Definition of AF “Atrial fibrillation is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation” NICE. Atrial fibrillation. The management of atrial fibrillation, June 2006.The ECG in AFNormal ECG ECG Diagnosis of AF Irregular RR interval QRS complexes are irregularly irregular Can be narrow or broad QRS Absent or indistinct P waves Baseline can show • Nothing • Irregular “noise” • Coarse activity a bit like flutter No regular patternECG Diagnosis of Atrial Flutter Classification of AF Terminology Clinical features Pattern Initial event Symptomatic May or may (first detected Asymptomatic not reoccur episode) Onset unknown Paroxysmal Spontaneous Recurrent termination <7 days and most often <48 hours Persistent Not self-terminating Recurrent Lasting >7 days or prior cardioversion Permanent Not terminated Established (‘accepted’) Terminated but relapsed No cardioversion attemptThe AF we find….. Or it finds us • If new onset AF with life-threatening haemodynamic instability then refer for emergency electrical cardioversion without delaying to achieve anticoagulation. • For new onset AF without life-threatening haemodynamic instability lasting <48 hours, assess CHA2DS2VASc score and offer anticoagulation where indicated plus either rate or rhythm control. If onset >48 hours, offer anticoagulation where indicated and rate control. • NICE 2021 NEW NICE: Diagnosis: • Perform manual pulse palpation if AF suspected. Perform 12-lead ECG in people with an irregular pulse, with or without symptoms, to diagnose AF. • If paroxysmal AF is suspected use 24-hour ambulatory ECG monitor if episodes <24 hours or 24-hour ambulatory ECG, event recorder or other ECG technology for an appropriate period if episodes >24 hours apart.What to do AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 18 AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 19Exclude or treat underlying cause • Bloods- U&Es, TFTs , CVD risk profile ( cholesterol, HbA1C) 6 • 12 lead ECG- or ambulatory if paroxysmal • Echocardiogram – for assessment of cardiac function 20 AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 21Symptom free and cardiac stability Improve heart rate: ( rate control) Aim for a resting heart rate of <110bpm AND without symptoms or continue till HR<85bpm in those with ongoing symptoms B OR C (+ D ) of drug options Rate limiting Beta-blocker OR calcium channel Digoxin blocker 22Rhythm options Ifsomeone remains symptomatic or intolerant of the rate control medication then refer for consideration of rhythm management, Rhythm Options: 1. Medication: (such as amiodarone, flecainide) 2. DC cardioversion 3. Ablation Note: AF never resolves, so anticoagulation should continue long term irrespective of current rhythm. 8 23 AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 24 CHA DS -V2Sc 2 Risk factor score C Congestive heart failure/LV dysfu1ction H Hypertension 1 A 2 Age ≥75y 2 D Diabetes mellitus 1 S 2 Stroke/TIA/TE 2 Vascular disease (prior myocardial V infarction, peripheral artery dis1ase, ormaximum aortic plaque) score is 9 since age A Age 65-74y 1 Score of 2 Sex category (ie female gender) or more = Sc 1 high risk Maximum Score 9 Lip GY, et al., Chest 137, 263-272, 2010 HAS-BLED Letter Clinical Characteristic Points Awarded H Hypertension 1 Abnormal renal and or liver A function (1 point each) 1 or 2 S Stroke 1 B Bleeding 1 L Labile INR 1 E Elderly (age >65) 1 Drugs and or alcohol (1 D 1 or 2 point each) Maximum 9 points 6/14/2023 HAS-BLED Letter Clinical Characteristic Points Awarded H Hypertension 1 A Abnormal renal and or liver 1 or 2 function (1 point each) S Stroke 1 B Bleeding 1 L LORBIT INR 1 E Elderly (age >65) 1 Drugs and or alcohol (1 D point each) 1 or 2 Maximum 9 points 6/14/2023 Aspirin • Great for heart attacks! …..not how clots form in AF! Risk of stroke and intra-cranial haemorrhage on warfarin according to INR 10 9 y 8 p 0 7 r 6 p t 5 r 4 3 2 1 0 <1.5 1.5-1.9 2-2.5 2.6-3 3.1-3.5 3.6-3.9 4-4.5 >4.5 INR stroke Intracranial haemorrhageDOACS Caution…. • *Apixaban dose should be reduced to 2.5 mgs if any 2 of the following apply: • Over 80years old • <60kgs in weight • Serum Creatinine> 133 • Rivaroxaban MUST be taken WITH food- without food the bio-availability is reduced to 65% ( WITH food it is almost 100%) • Dabigatran cannot be used out of the packet so is not suitable for “dosette boxes” Long term monitoring • Adherence • Adverse events • Additional/new medications ( including OTC) • Suggested bloods: • ALL- annual LFTs and FBC • CrCl >60 Annual U&Es • CrCl 30-60 6 monthly U&Es • CrCl 15-30 3 monthly U&Es Remember • Age • Body weight • Creatinine Clearance • Drug interactions • Remember: with every prescription we must think concordance In summary • Keep looking for AF • Remember stroke prevention