Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Understanding 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 • The prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age 50–59 years to almost 9% at age 80–89 years 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 younger and older patients 1  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 2021 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 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….. 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 48 AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 49Exclude 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 50 AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 51Symptom 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 52Rhythm 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 53 AF confirmed Exclude/treat Symptom free Stroke underlying and cardiac prevention cause stability 54 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 12/7/2023 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 12/7/2023 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 To fast or not to fast? Random sample • Total cholesterol / serum cholesterol / TC • HDL Ideally fasting sample • LDL • Triglycerides Triglycerides Fasting triglyceride (TG) below 1.7mmol/L Non-fasting triglyceride (TG) below 2.3mmol/L • If TG is 4.5 – 9.9mmol/L look at the >7.5mmol/L REFER.on-HDL) if • Isample (one third will return to normal) but if fasted TG>10mmol/L REFER. • If TG >20mmol/L REFER URGENTLY. Consider FH All Individuals whose total cholesterol level is found to be above 7.5mmol/l should be referred to their GP for consideration of Familial Hypercholesterolaemia (FH) and for cascade testing of family members if a FH diagnosis is confirmed Check: Full lipid profile Thyroid, kidneys, liver and for diabetes Ratio Total Chol HDL RatioNo targets Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 / 1 6 / 2 6 / .8 8 / 2 Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 / 1 6 6 / 2 3 6 / .8 7.5 8 / 2 4 Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 bad / 1 ok 6 bad 6 / 6 / 8 / Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 bad / 1 ok 6 bad 6 bad / 2 good 3 quite good 6 / 8 / Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 bad / 1 ok 6 bad 6 bad / 2 good 3 quite good 6 bad / .8 bad 7.5 very bad 8 / Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 bad / 1 ok 6 bad 6 bad / 2 good 3 quite good 6 bad / .8 bad 7.5 very bad 8 V bad / 2 good 4 very good Ratio Total Chol <5 HDL >1 (>1.2) Ratio <4.5-5 6 bad / 1 ok 6 bad 6 bad / 2 good 3 quite good 6 bad / .8 bad 7.5 very bad 8 V bad / 2 good 4 very goodHowever, emerging evidence Non HDL Total chol HDL 6 1 6 2 6 .8 Non HDL Total chol HDL 6 - 1 5 6 - 2 4 6 - .8 5.2 Targets…..NICE Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment (both primary and secondary prevention, including atorvastatin 20 mg for primary prevention) at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol. If a greater than 40% reduction in non-HDL cholesterol is not achieved: • discuss adherence and timing of dose • optimise adherence to diet and lifestyle measures • consider increasing the dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement.www.heartuk.orgHeartuk.org.ukQoF 23-24 Could stay messy New Nice 1.6.1 could recommend New QOF indicator CHOL002 non-HDL < 2.6 or LDL < 2.0 non-HDL < 2.5 or LDL < 1.8.