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Understanding AF @LWNurses #LearnWithNurses Michaela Nuttall RGN MSc Founder, Learn With Nurses Director, Smart Health Solutions Clinical Advisor, PHE Associate in Nursing, C3 Collaboratingfor Health Chair, Health CareCommittee HEART UK Member, Nurses WorkingParty and Guidelines & InformationWorkingParty, British and Irish Hypertension Society Trustee, PoTS UK and Bromley Third Sector Enterprise @ thisismichaelaUsing Medall.orgClosed FB group & PageUnderstanding AF AF across the world • A total of 3.046 million new cases of atrial fibrillation worldwide were registered in the database 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 Prevalence of AF Increases with Age • Theprevalenceof AF roughlydoubleswith each advancing decade of age, from0.5%at age 50–59years to almost 9% at age 80–89years 11.1 12 Women ATRIA study Men 10.3 %10 9.1 e c 8 7.3 7.2 e a e 6 5.0 5.0 r P 4 3.0 3.4 2 0.9 1.01.7 1.7 0.10.2 0.4 0 <55 55–59 60–64 65–69 70–74 75–79 80–84 >85 Age Analysis of adults aged ≥20 years, who were enrolled in a large health maintenance organisation in California and who had AF diagnosed between July 1, 1996, and December 31, 1997; AF=atrial fibrillation; ATRIA=AnTicoagulation and Risk Factors In Atrial Fibrillation Go A, et al. JAMA 2001 ;285(18): 2370–5 Variation There is huge geographic variation in prevalence across the country depending on the demographic profile. At a GP level, this can mean prevalence ranges anywhere from 0.009% to 27.5%. Risk of Mortality with AF Framingham Age 55–74 years Age 75–94 years Men AF 80 Log rank 42.90 (men) 80 Log rank 51.44 (men) (n=53) 70 70.93 (women) 70 101.51 (women) i ) 60 60 Women AF a ( (n=47) d p 50 50 Men no AF t u 40 40 (n=6999) e l 30 30 Women no AF b f S 20 20 (n=8307) 10 10 0 0 0 1 2 3 4 5 6 7 8 9 10 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Years of follow up Years of follow up  AF approximately doubles the risk of mortality in both 1 younger and older patients  Two-thirds of deaths in AF patients can be attributed to CV 2 causes 3  Risk of death is similar for men and women with AF 1. Benjamin EJ, et al. Circulation 1998; 98: 946–52; 2. Lévy S, et al. Circulation 1999; 99: 3028–35; 3. Stewart S, et al. Am J Med 2002; 113: 359–64Where are you going to look for AF?UNDERSTANDING ATRIAL FIBRILLATION 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. AF and Pre-existing CV Disease • People who develop AF usually are elderly • AF is often a manifestation of underlying cardiac disease, such as: – Hypertension (especially if LV hypertrophy is present) – Valvular heart disease – Heart failure – Coronary artery disease • AF may also be associated with: – Cardiomyopathy – Congenital heart disease (especially atrial septal defect in adults) Other Causes • Thyrotoxicosis • Rheumatic heart disease • Digoxin Toxicity • COPD • 5% unexplained 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 AF Risk of AF Increases Along the Cardiovascular Spectrum Remodelling Ventricular dilation MI Heart failure End-stage Atherosclerosis microvascular and LVH and 1,2 heart disease AF Risk factors (diabetes, Death hypertension ) 1. Benjamin EJ, et al. JAMA 1994; 271: 840–4; 2. Krahn AD, et al. Am J Med 1995; 98: 476–84 AF as a Co-Morbidity Makes bad things worse • Increased mortality after MI • Increased mortality after stroke • Increased risk of stroke recurrence • Worsening of heart failure • Increased risk of sudden cardiac death in advanced heart failure • Increased hospital admissions and length of stay in all casesAnatomy of the HeartThe Conduction System Symptoms of AF  Patients with AF present with a wide range of symptoms, or can be asymptomatic LIGHT- PALPITATIONS HEADEDNESS SYNCOPE DYSPNOEA FATIGUE CHEST PAINWe have to look for it…We have to look for it… 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 2021AF – diagnosis and treatment In summary • Touch your patient • Look for AF • Keep looking for AF