Cardiology - Pharmacological treatment of Atrial Fibrillation



This on-demand teaching session is relevant to medical professionals and entices them to attend by providing an overview of atrial fibrillation, which is often hard to detect. The speaker touches on different symptoms, treatments, and prevention methods, while highlighting why it's important to treat it - its five-time increased likelihood to cause a stroke. The speaker also aptly explains how to detect the fibrillation and how to use the CHADS2 tool to calculate risk of stroke. Attendees will have a better understanding of when and how to treat atrial fibrillation, as well as its consequences for patients.
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Learning objectives

Learning Objectives: 1. Describe the clinical implications of atrial fibrilation with regards to stroke risk. 2. Explain the causes of atrial fibrilation and the different types of atrial fibrilation. 3. Identify atrial fibrilation on an EKG. 4. Discuss modalities of treatment for atrial fibrilation. 5. Utilize the CHADS-VAS score to determine the need for anticoagulation to reduce stroke risk in atrial fibrilation patients.
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Computer generated transcript

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

whenever you're ready, Doctor. Seems the doctor may have frozen uh, my Spare me while I get my presentation. Um, sorted. Okay. All right. So today we're going to be talking about atrial fibrilation. And I'm I'm aware that you guys are already hot, um, Elektronik on a trip relation in terms of hard to detect it. So we'll go through that. I'm so much this time around, but I'll talk about about the treatment and the names of it and why it's important that little fibrilation is detective for starters, and that is treated and how we need to do that. So, a year from relation increase, this is the likelihood off stroke by five times. So that's why it's really important that at every opportunity that you actually have with the patient in front of you, you take the opportunity to do a pulse. Check in on that pulse. Check if you pick up the atrial fibrilation and get them again. The CT done for that patient to confirm the intra fibrilation. Now, can anybody remember from the lectures that had previously how you can tell from a knee cg The patients got atrial fibrilation. It is usually the presence of F wave weight flutter. So that's the initial flatter. But what about from relation? Um, but I always So I say that again. You know, I love with Sorry, I didn't quite catch that up. Is everything chart books? Okay, I'll I know. Yeah. Colitic ways. Bunch of know that there is a There is a very easy way to tell when somebody atrial fibrilation on. I'll show you that in a couple of flights, and it's a really easy way in somebody who's never even seen any. See gi would be able to pick it up. So I'll show you that in a little bit. No p waves. Correct. There we go. So f is when you put on irregularly irregular heart beat. Okay, If you look, cut it here. This is what atrial fibrilation would look black on any CD. Can you see here? Normally you have a P wave here, right? P Q R s. Yeah, there is No, there's an absence of the P E wave here. Yeah, and if you can see the distance between each of the peaks here, they're all different as well. Therefore, you about this irregularity or regular irregular heart Be okay now When I'm explaining this to patients, I tried to explain it to them. In terms of music, there's no he's gonna Nobody's going to understand what the hands a regularly irregular heartbeat. I'll be even means so I went to them like music. I said that, um, if your heart isn't be, it goes from from from, um, it's on the beat. However, if you got atrial fibrilation, it's like a zit. Your heart is playing jazz music. It's all it wants to be sort of all over the place on. But that's how you got atrial fibrilation. But having atrial fibrilation, what does that, actually, what does that actually mean for the patient itself? Like I said before, it does increase the risk of stroke by five times. Just why really important for us to treat it? Does anybody remember how atrial fibrilation sort of comes about in the heart? Um, dial it and enlargement of the atrium from like evolved effects such as much about the fact you can take it can be, uh, so what else can cause atrial population? It's a listen to you to that the essay, noon and the maybe Node not communicating. Correct. Good. Yeah, absolutely. Anything else? Hypertension, Chris. So we were looking at, actually. So you said 22 of the main thing, which is really good that the thing would be is when your electrical activity normally originating from the essay load, would come from anywhere else. So you could have multiple points within the atria that your electrical conductivity starts from. So you could have, like, instead of having just the s a note, you could have maybe three electrical stimulations happening at any one time going Teo, the eight, the note. So if you're if you're stimulating, so many different parts of the atria is gonna go is gonna go like this. And what that means is that whilst the 80% of the blood you know is trying to flow through to the ventricles, you've got that little bit that's trying to be pumped know after going through to the ventricles because the atria are not being able to be properly on their four Normally, what can happen is in your left atrial appendage, you can get a clot building up in them. If that clot then breaks off and exactly around the body. It can then cause a stroke. If you caused a P E can cause a DVT if in court, a clot anywhere in the body. So that's why you may have had left atrial appendage. So if you haven't out, they look that up and you can see where it is. It's just like a tiny pocket on. But with the atria is on. That's where normally you get any sort of deposits happening because the blood is therefore pooling at that place. Okay, so you get different types of atrial from relation as well. So you get paroxysmal atrial fibrilation, which means that last less than seven days, you got persistent atrial for relation, which last for more than seven days, and you're having a liter of population which can happen all year round. And then, obviously, then you will score atrial flutter as well, which, if something, for it for flutter, a lot of conditions still treat it the same has a formulation because the risk of clot could still be there as well. So scientists in terms of the actual population, so your patient might be seated in front of you and my feel breathless they might have dyspnea they might experience palpitations and palpitations. Probably one of the most common things that patients tend to feel palpitations alone wouldn't make you ruler in atrial fibrilation, cause obviously, as we know that there were different courses of palpitations on that patient could have a swell they may feel sink your dizziness, they make it, they make it the chest discomfort. And actually, some of the time patients may be admitted into the hospital with having a stroke or a t i a, um And then they may have picked up the stroke with the T I A was you to the fact that the patients got atrial fibrilation. So I know that you've been through this before. So again, I'm just going to briefly go through it. So your opportunities for diagnosis and what? How you need to approach is firstly, at every opportunity with the patient, you get a pulse chair is so quick and easy to do. I'm sure you guys order You know how to do pulse check. Follow the thumb radial artery. And you found your pulse really quick and easy. You know, I've got well, you know, a doctor over here in the UK who does it every time he was shaking hands. You take. You know, if you check hands in a particular way, that would enable him to essentially check the pulse off the patient in just a quick second. He's able to pick up with a patient. Could potentially have atrial fibrilation. So he felt one pulse. Check that. You know, you notice that patients got a new regular pulse on, then you'd get in CG done. The EKG, as you're currently identified, may show that the patient has an absence of the P E wave. If there was an absence of a pea way, then you have confirmed your age of population. Now, when it comes to treat when it comes to treat well, you're looking up a rate control. Our best is a great control vested. Rhythm control first sign is always rate control. Okay, so we're looking at things like by stop along, for example, and we also anticoagulated the patient. The most important thing is to anticoagulated patient. You want to get that blood stained so that you don't get that pudding or blood in the heart and preventing on the clock from warming and that therefore you preventing like a stroke from a carrying this well and then you also want to check. You also want to refine the patient. For echo is, well, you want to check to make sure that they haven't got any heart failure, because sometimes that can happen. You can see that some of the symptoms can sometimes process over with heart Failure is, well, she just want to make sure that there's nothing else that's going on them with the heart as well. So before you treat the patient as well, you want to make sure your that you've done a chance fast and in orbit school. Have you guys heard of chance of us before in a while before, um, can I ask? You have a chance? Okay, you may have had a husband, so husband was sort of at the pretest toe or if you like, and there are some areas that still use Husband, especially the European Society of Cardiology, have still said that they would be using husband so you can use husband or you can use a little bit. But in the UK, we have been we have been told that actually orbit is the preferred option. Teo, you know when you're when you're trying to find out. So what does anybody know? What chance of ask? Actually tells us, But not so anti coagulated patient. No, no, it doesn't. No, she shows up. Um, a chance of getting a stroke needing with Yes, it is the chance off the patient having with a stroke. So what's really important here is if your patient is is less less than 65 years old, then a lot of the time they don't treat the patient until they have reached the age of 65. But you also still want to consider if they've got any other co morbidities. So you still want to be quite strategic when it comes to treating patients. So I used. So I have this. This is from mg Kulka website. I was really good on day one ever. I'm having to calculate the patients risk off them having a stroke. This is what I use to say. For example, if he had a patient whose age between 65 74 then you click that one and that gives you a score of one. If they're female, then they would score another one. If they've got a background of cardiac, uh, card, cardiac heart failure or CHD or anything like that, then you will also select it. Yes, if they've got a history of hypertension than they would get acquainted. If they've had a stroke, t I a lower another clot somewhere in the body in the path, then they get they get two points for that. And if they've got any history of muscular car history of us, the disease, some things I, um, I will perform off disease or anything like that. That scored another point that it's got a history of diabetes and they would score another point. So as you accumulate in more point, the more risk you have off actually having a stroke. So normally, we would say, If you're if it's greater than it is greater than one in the mail, then yes, you would need to treat I'm in a female if it's greater than it was greater than one of this is going to, then you would definitely treat these patients on. This is all outlined sort of been the nice guy bowling guidelines that we have to say when you should and should not treat, you know, with anticoagulants on bend. That sort of helped you helps you to put it into context or what the patient's risk is. Um, so when it comes to the orbits, so does anybody know what the what the school is? Says hemorrhage. Yeah. So you're assessing the risk of bleeding. Okay, so this all. So what's really important when the constable husband and a little bit school is that it is not a reason not to anticoagulate Cargill eight somebody all it does. It highlights what any modifiable risk factors the patient may have so that you can you can prevent them from having a bleed. Obviously, there are some things that can do that you can't change. You know the gender of the patient. You can't change their age, but when you can do is protect them from any bleeds from happening in the future from from giving them. Bring things like Page two antagonist to protect the stomach or keep the eyes to put a stomach. So things like, um metrozole lands up Xolair and things like that. You can also see if there's any issues with the kidneys and try to rectify that. And if they're obviously cause any people with underpaid agents that at that point depending on why the patient is on any anti platelet agents, you would switch them to, um, anticoagulant. But it is dependent on why they are on any anti platelet agents. Because if a patient has had a heart attack in the last year, for example, and they also have atrial fibrilation within that year, they would need to be on aspirin, plus the second antiplatelet, plus the anti coagulation for a certain amount time. The anti coagulation will be lifelong, but the aspirin and second Asian would not be life long. And it's only in the under very special circumstances, which would be dictated by the consultant where you would have aspirin and when you would have an anticoagulant together. So then that's what. Dependent on the risk with the consultant, I would put it over. Obviously, currently, the treatment with the country where we look rate control versus rhythm control. So our God, I can't say that the first thing that he should do is control the rate. Okay, so the rate of your heart so say for example, it's a patient had atrial fibrilation, and the pulse rate was say, you know, 96 for example, you would consider actually, you would start the patient on Bicipital. What's really important is with my supper a little. The rule always start low, go slow. And that means that when you try treating this medication, you want to titrate the bicipital, but to be exact time, so you start about 1.25. You go to 2.5 to 5. You get to 7.5. You get 10 minutes as much as the patient can tolerate until you get to a resting heart rate off around 60 to 70 BPM. So that's really important to make sure that patients actually rate controlled well. And you live now. These cardioselective beater blockers, things like by supple on and live along, topple onto those are the ones that target the beater receptors on the heart. If that doesn't work and the patient's heart is still not well controlled, you may consider adding in some digoxin. Then what's really important about the Jobson is the doctor is very good in patients who are essentially immobile. Occidente really you know, you So you look like you're sort of frail patients s. So that's why digoxin to speak good did they don't tend to have a side effects of the toxin. Um, and then therefore, we tend to go return to go with digoxin for those patients. In addition to that there. If that lives in work, you got a few other options as well. You make, consider, then rhythm control. So then you got the pharmacological cardioversion that you got coming on a swell. So this is amiodarone amiodarone in it. That's the one. That probably is the rhythm of the heart. So with pharmacological cardio inversion without your drink, you have a loading dose that you have to do an excuse slowly increase it every seven days. Um, yeah, yeah, that that's how that so you say decrease after seventies. That's how it's going to work is that, um, usually stays in the body for a very long time with because it stays in the body for a really long time. You also have to monitor the side effects off amiodarone as well. Um, and just could anybody tell me what the side effects of, um, you know no Any any ideas of what you may need to monitor Before you saw the patient on, um, your drink, the coughing teacher. So you say that again. Golf like, uh, fat and dizziness. And, uh uh, Yeah, So you want to do X ray on the patient because they can develop things that pulmonary five by process on. The other thing you want to do is an eye check, a swell to make sure that they don't develop any anything wrong with the eyes. The other thing? Unity is about thyroid function control as well. Cause I'm you're doing can affect the thyroid function. Now, when you're learning the patient on, um, your drug that normally what we do is 200 mg three times a day for one week, then we reduce it to 200 mg twice a day for one week, and then maintenance dose is normally 200 mg a day. That's normally what we do in these patients are not normally on it. Long term, they're running for a short time only, and that's purely due to the side of bags off the amiodarone is kind of kind of falling out of favor now, the other option that you actually have is a direct cardioversion, which is basically shocking the patient back into rhythm. So when you shock in the patient back into rhythm, you actually need to make sure that the patient is actually really, well anticoagulated. Otherwise, you may throw off a clock. So on when we come want to talk with my anticoagulants, you'll see why that's important. Do you do get seven types of patients when their atrial fibrilation comes along very randomly and they can. They can feel it in those sorts of patients where it's very random might be few and far between, but they do get the symptoms of it. You'll have something called the pill in the pocket, which is normally flecainide, and the dose of that compare in between 50 and 100 mg. So this is only use for for patients who can feel when they have palpitations. Okay, if the patient cannot feel when they got palpitations, you would not give them a pill in the pocket because it would be useless. Okay, so now we're gonna talk about anti coagulation, prescribed having principles. So this is this is really important because There are a lot of things that you sort of have to consider with the patient themselves. So we started off with only having to anticoagulants. He had simple. And then you had warfrin. Okay, with both of those, you have to measure the iron A. Yeah, Come 2000 and 10, you have the big A time 2011 rivaroxaban 2000 and 12 picks about in 2015. Finally, Adoxa Bon. Now these all target the different pathways off off the clotting system. Okay, so with the bigger try and it's a direct thrombin inhibitors with the rest of them, they're a little factor 10 a. Inhibitors and that basically promote thinning the blood. You don't have to do any iron arm. One of things that I know stands for stands for in a self international normalized ratio, and that will basically tell you have been or thick your blood is for patients who have atrial fibrilation, normally they're talking would be 2.5. It would be their target when you're measuring the iron and this is the types of patients that you really want to sort of start on. A dose pack is if they're talking on or is 2.5 And if they've got atrial fibulation now is really important. This is non valvular A yes, And what we mean by non valvular a m is that they don't have a prosthetic heart. All which is a metallic warm metallic are 12. I should say they don't have a metallic heart valve on, but, um, that's been in put inside of their heart. If they got metallic hot bath that they have to stay on warfarin or Synthroid, that is that is one of the only thing kind of times when you can use of Doc is when the patients got metallic are well and you normally know you can only hear it when you when you hear it through a stethoscope. A swell. So when we look at the different trials, I've just shown you a few of them. So I fix a band a bigger town and revoke rivaroxaban here. There were all really excellent trials, you know, international multi center, double blind double dummy placebo. Randomized control with with picks up on rivaroxaban was double blind, double dummy and difficult channels. You, which was the al you one on was an open label trial, and you can see here you had a really big co holes there, really big amount of patients and they looked at what? They're different iron. Ours were in each of those studies, so you can see here it wasn't, You know, these are relatively low on arms. Actually, they can see what the what The parents of stroke was within the year and actually was very, very, very low. So that's why these trials showed that these new drugs, the doors are just as good as warfarin are preventing stroke from happening. But when it came to their safety profile, this is why the preferred over warfarin, if you can give them, is because off this major bleeding incidents. So if you can see here with the warfarin, the incidents with three point is there a 93.363 point four back. She, um, with picks up on, um, the major bleeding was to put three difficult trust 3.1. RIVAROXABAN was 3.6 and can see that that's actually like quite that's a little bit significant. But if you look at the types of bleed, the types of reading with your prevalent in each off these drugs was different. So with apixaban be Although the major bleeding compared to war friend overall was was low the type of bleeding which was most prevalent Waas intracranial bleeding with rivaroxaban it was actually G. I bleeds. So these are the kinds of things that you need to take into account when you're considering starting patients on antifibrinolysin. Has the patient had a hemorrhagic read in the past, for example, with him, you know, in their brain, In which case I probably wouldn't go for a picture on if the patient has had a G. I bleed in the past that I may not go for a miracle, Savan, because it's going to exacerbate an increase, the probability of them getting the bleed. And this is why patient choice and making that shared decision making is actually really important. You have to be able to discuss that with your patients who you know what they are going to prefer. So you may be wondering, you know, one of the one of the benefits of you know, off these New York drugs, these Dolax and you know So I've just done a comparison table here, where you can see with warfarin, you have to have regular iron. Are monitoring patients are limitations to the activities. What I mean by that is you have to control, uh, you know, you have to control how much how much leafy green vegetables you were taking. You know, patients that, like, is if they couldn't go call thing, they couldn't do exercise because it was so scared of having a bleed and those sorts of things. You had more food and drug interactions with warfarin. Um, like I said, that green leafy vegetables and reason for that is because green vegetables contained between K vitamin K actually them is the antidote to warfarin. So some of these are really high. I know. If you give them to make a, then you actually bring the iron or back to normal. And that's why these patients have to make sure that the that the intake of leafy green vegetables was consistent throughout the year. Otherwise, it would all of her there I in our results, quite a lot. And then therefore you get changes and dozing. Um, like I said, with warfarin, you don't get a standard dose you might be 2 mg of warfarin one day, three minute problems the next day, formerly bronze another day. So it kind of buried is reversible, though then you can measure to see how thick a cious to it efficacious, efficacious. It is because you're measuring the patients I know with the door wax. It is more expensive initially, but actually you have to monitor less because up to monitor less. It means that there are little bit more cheaper than warfarin is because you don't have to do so many blood tests. And because some of the Doryx they've got quite a day dozing. It means that you do have a shorter half life, which is good, but you also might give the rice is the compliance issues. Obviously, this may not be this would not be the case with Rivaroxaban or a doctor because they're once daily dose seeing. Now the big trunk is the only one that's called Reversible Agent, which is widely available. Onda and Apixaban and Rivaroxaban. While they do have a reversible agent, call a dexa net. Certainly in the UK, it's a bit difficult to get your hands on and other places in other countries that may, That may not be the case, so So at this point in time, you know it is difficult to reverse it, but sometimes they'll do. Plasma infusion is the dose sorts of things. Teo. Limit the bleeding. That sort of happening. It is a standard dose ing, so we'll go introducing a little bit afterwards. This book, for example, with the picture violence 5 mg of 2.5 rivaroxaban is 20 million lbs. 15 the bigger trying. It's 150 or 110 s o a doctor by the 60 or 30 and you're seeing why you've got these varying doses A Z Well, um, in the in the deluxe regular, I am what I a normal thing is actually not required. You probably just need to do a blood test once or twice a year just to check what the kid any function is so that you know that what the dose is right. It is significant reduction of stroke compared to warfrin s. So that's what's actually like, sort of driving it here a swell. So that's playing absurdly in our guidelines, we say Dolax off assigned unless the patient called Warfrin on. I'll go over situations where the patient would have to stay on warfarin. So indication of anticoagulation office, See if is not the only one. So when you're clocking in patient and you're trying to and you see you know, if it is that they're anticoagulant, think and ask, Why are they on the anti coagulation is because they have atrial fibrilation? Or is it because they got pee? Do they have a metallic valve, In which case they should only be on warfarin or Synthroid? Oh, did they have a DVT? And it didn't have a proof for a vascular disease. So therefore you might see rivaroxaban on a low dose, which is 2.5 mg. You might have a patient who's the coast and my impatience. If you can tolerate aspirin or carpeted world, which is again, you would give rivaroxaban low dose in combination with the two antiplatelets. Sorry, the one and two fatal in that case, Or could it be prophylaxis off bte following the total knee replacement hip replacement? So they want these. There were these considerations to have so don't miss you that the patient may be on anticoagulation for atrial fibrilation always find out the reason why you're on the anti coagulation. So ask yourself, why is the patient on anticoagulation or why do they need to start anticoagulation? Is the drug the right choice? Is the dosings appropriate? Or does it does? Adjustment is or is it just adjustment required? Think about what is the patient's renal function. Think about what their weight is. Think about what the age is. Think about what the target I A normal is that is the patient on any medication which couldn't interact with the door. So we're looking at things that quad level world capitals, turmeric capsules, the anti epileptic medications and these are really, really important things to consider once they're beating rest of you, looking at husband or bit school. And also, what is the strength risk looking at your chance Pass school, and I'll tell you whether you need to treat or not true. So remember, when you are prescribing deluxe, it's a B C, a body weight in crafting clearance. Those are the big three things that you need to consider because they make a lead to dose reductions or a different choice off anticoagulants. So so depending on the age to say, for example, with the picks up on if they're over the age of 80 then you may have to reduce the dose, especially if they're crowning. Clearance is also porous. Well, then you also have to look at their body weight. If the less than 60 kg, then you may have to change the dose in a swell, and we'll come on two doses a little bit later on. I got a good table, but for now, just remember your A B C's age. Bodyweight. Chronic chronic owns the missile. Makes sense. Does everybody know what you need to use to calculate? Cramping? Clearest. By the way, could you repeat the question, please? What do you what do you use to calculate the creatinine clearance? Good way the disease in a glimmer. A few tree. She waits, too, depending on everyone teeth. Well, it's funny. You say that because sometimes blood test results may report as each year or which is estimated glomerular filtration rate. If it's estimated glomerular glomerular filtration rate, it's not taking into account the patient's weight, the patient's age or their height, which means that actually easier for would be inaccurate. So when you do want to use to calculate the creatinine clearance, accurate be is using Cockcroft and gold equation Now again using MD Kulka, you can you can use that a website and you plug in with the patients ages with their weight is what they're creatinin is. And you also put in what the height is a swell, and I'll give you an accurate creatinine clearance so that you know how you need to dose your patients appropriately, and that's really important. Unfortunately, what tends to happen is doctors and doctors and training don't get tour that you need to use creatine clearance. Not easy fr when when dozing door. Then you must remember that for for drugs, which I've got narrow therapeutic range is a swell, so that's really important. So what calculation isn't called crafting gold? Thank you. Uh huh. So these are the some of the dosings that you're finding apixaban. So if you find that patients got DVT or a piece of skin usually diagnosed, then the dose of apixaban will be 10 mg twice a day for seven days. Then you have 5 mg twice a day for up to six months they will be up to the consultant HEMOTOLOGIST to then decide whether the patient needs to have the 2.5 mg twice a day, which is the dose approved relaxes of beauty. And this really depends on weapons, for the patient has had multiple DVT's on weather. The patient has had a provoked DVT. I eat because of something or unprovoked I need you can't find the course for any spontaneously happened. So if it's spontaneously happened, then you may consider putting them on a prophylaxis off 2.5 twice a day. Now what? They come to the dose off. Atrial fibrilation is going to be 5 mg twice a day. Okay, or it will be 2.5 minutes just fine estate. If the patient is greater than eight off 80 if their weight is less than 61 kg, or if the serum creatinine is greater than 100 that we might most relief, which may mean that the creditors between 15 and 29 mils per minute Now you need to have two out of three, um, off these considerations to then going to the 2.42 point five rebounds twice a day unless the pregnant clearance alone is less than that was permitted, in which case there be on 2.5 mg twice a day with Rivaroxaban for again for treatment of DVT Oh P E newly diagnosed the 15 twice a day for 21 days and then 20 minutes about once a day thereafter for Prophylaxis, VT. And maybe 10 minutes once, once that once a day or the may get down to 10 mg once daily, which is again at the discretion off the consultant HEMOTOLOGIST. For the dose and a F, however, it would be 20 minutes on one state E. That's only if the creatinine clearance is the bump 50 mills permitted. If there crapping clearance is less than 50 miles a minute, then you would put them on 15 mg once daily, Um, and again if the patient has had in the coronary syndrome on. But, uh, you know, you have to spend it with aspirin walk lipid. Well, then there would be on 2.5 mg twice daily for 12 months. Okay, so remember about this considerations that I said, you know, does the pressure does the patient perfect twice a day does seem to be prepared once day dressing. Have they had previous? Have you had previous bleeds in the past? Where have those bleeds been? What other medications are they taking? That could potentially be interactions with these medications? And the big one's always anti epileptics. So this is the really nice algorithm that we have here about how to dose patients with non valvular atrial fibrilation. So you would calculate the pregnant clearance for rivaroxaban. And it is less than 15 minutes committee. Then you would not give them rivaroxaban. You may consider things like warfrin or Centrum, and generally speaking, here you can see if it's less than 15 mills, then you would know Give them the door for you would give them warfrin. Okay, um, if it is between 15 and 49 for Rivaroxaban, then you would give the 15 mg once daily. And if they're pregnant, clearance is great and 50 then would be 20 mg. Staying with apixaban. It's slightly more complicated, but the evidence is very good for it's still you just have to know how to calculate the creatinine periods. And as I as I mentioned the years with often gold, so here if the patient has a cramping clearance between 15 and 29 was committed. It's always going to be to put 5 mg twice a day. If the patient's creatinine clearance is greater than 30 miles permitted, then you want to check their age. If the greater than eight years check the weight possess and 60 and they got more than two features, and it's gonna be 2.5 mg twice a day if they're gonna go. One feature that will be 5 mg translates to say, for example, if your patients in the 18 years greater than 80 years, but they're way to say 66 kg and crap in the in the same Kremlin's less than 193 then they would still be on 5 mg twice a day. Okay, then we got the big trunk here again, which is excellent data. It does come with a lot off those changes, though. Andi, enough may need you to you know them interacting with things like verapamil for, for example. But yours will be in either 150 mg twice a day or 110 mg twice day and again you need to take into account the renal function and you need to take into account the age as well with with Adoxa bam again, which is, um, similar to rivaroxaban. Um, if the patient has gotten pregnant place between 15 and 49 then you give them 30 is greater than 50 than 60 mg once daily with the weight is less than 60 kg and would be 13 with bones daily. Thea Other thing to consider with doxepin is that if you if you can't get the cramping clearance is greater than 85 mils per minute. And actually relationship have been receiving a doctor around because the efficacy is not there on. Do you know there are studies to essentially show that if you got really good renal function above 85 miles a minute, then actually you're the amount of oxygen in your body is less. Eso is in that sense that you want to, uh, explore giving the patient one of the other door. So these are the consideration. Does the patient have a dossier box? This is everybody Know what a Doucet boxes? Oh, I don't know. Yes, it's the books. I don't see patients to keep talking The medication is still on more than one, but a few tablets. Yeah, and then always elevated. But I don't forget, you know, always elderly. Sometimes people get you know you've got arthritis, for example. They may struggle with opening boxes. So what A Dossett boxes it says. Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday along one side of it. And it says, morning warning, midday evening and bedtime. And then what pharmacy does is that they put the medications into the relevance starts when the knee jerk she take the medicines and all the patient does is pop them out in their hands, and then they take them according to the day of the day of the week and then time of day that they need to take that. So it's actually really good weight loss. Um, monitoring the patient's compliance is well, so with dabigatran, the bigger try and calm go in Dawson boxes, though, so that's a consideration. If that does the patient have renal impairment, you many travel dose reduction has the patient had a recent heart starts, in which case the patient may be up to therapy If the patient was last spring prior, uh, and they haven't had a hospital in past. Then you would switch them over to the door. Okay. Has the patient had a clot whilst they been on a door? In which case you would give them or furnace in through? Really? Does the patient having mechanical balls? That's the metal bar. Those with you, then they can have symptoms, really is a patient and concerned about reversal Agent, In which case only practice buying, which is for the bigger trend, is from the available. The other thing to consider is there's a patient have passed benefits and room at the patient has possible it'd syndrome. Then they can only be on warfarin or Synthroid own. So that's the only other situation as well. So you said if they've got Dossett box, they that means they're not on the big trunk. I, um that's why it's that basically, there are certain there are certain drugs and put them into dusty boxes they can essentially degrade. They're not like, you know, you know, stable. Yeah, they're not stable. So you know how like, for example, Nicaragua Oh, Nick around Oh, will come in metal blister packs and then you've got one little one little one right at the end, which, basically and keep all the moisture away from the neck around middle like the bigger channel doesn't have that. So that's why you can't put it in the bus it box where I've Adoxa ban picks, a band and rivaroxaban They're not affected by water. They're not affected by moisture and things like that this stable in the dossier box so you don't get any degradation of product. Um, so that's why actually you can put the others in the Dossett books. Thank you. No problems. So when you switching patients to do cracks? And now this was a massive thing because of the pandemic, we've had to switch a lot of our war from patients who may have been on it for atrial fibrilation to go after. This is why I'm telling you guys, because you may, you may find that, you know, this is something that's actively happening where you guys are Well, so firstly, let's think about who shouldn't be switched. So we've already said, plus, prosthetic mechanical bowel, if they've got moderate to severe mitral, still notices if they've got antiphospholipid syndrome, if the pregnant or breastfeeding, If it was severe renal impaired. And then, if they were active malignancy or chemotherapy than they should not be. Sweet certainly would know without the import off, off the off the cancer consultant. And there is more evidence coming out now, especially for things like liver oxygen. Safe use in patients who have got cancer. If a patient's got target, I know above 2.5, and they should be switched if the prescribed any drugs that interact discussed with any specialists if they are anti epileptic for triple therapy. If now this is a very contentious issue of the moment when it comes to body weight, If the patient has a body way above 150 healers, they cannot go on a door work. Not because we don't have any information about the distribution of off the drug. In patients who have got who have got a weight greater than 100 50 killers now up to 120 kg, they can have it. But if they slide above 120 years, you may want to seek advice or anti coagulation hemotologists. They may want to do anti 10 a levels, which is a blood test, which can be requested from hematology. Some patients may turn around and say to you, I know above 120 kg while I don't want to go on walks and I don't want to go on Synthroid. This is a risk versus benefit, and you have to be able to explain to the patient with the risks and the benefits are. And if they want to, then still go into a dog knowing what their risk off stroke or anything else. Maybe then, obviously, that's That's a conscious decision that patients made. And you have to be able to respect that. Um, if the patients got BTO unusual sights and sometimes I have seen patients who about clots in their arm, you cannot have a door for that if they've got a clot in the ventricle of the heart, cannot have a door for that and is also caution in liver disease as well. Which is asked her Thiebaud, it's the part of the specifications in that the manufacturer bring out as well. So when you're going from warfarin to any of the dough axe, the first thing you want to do is you want to imagine the iron arm in the patient. Then you want to stop the warfarin. And if the owner is less than two, then you start up the bill back. If the iron I was between two and 2.5, then you saw the bill out the next day with the rocks. Yvonne, it's special because you can you can measure the eye and I'll stop the warfarin and you can start rivaroxaban when the iron or is less than three. So that's the difference between those three and rivaroxaban switching patients to warfarin. However, this is really interesting. So patients may Vesely have clots whilst they are on the dollar for any number of reasons why I really seen this happen a couple of times. We see you know you'll see happen sometimes the hospital. But what you would do would start the treatment with the warfarin, and you do not stop the doc. So, for example, you would prescribe warfarin and picks about at the same time until the patients I in our with is within range and likely that I know it's gonna be a higher target. Me because he had a clot Watts have been on an anticoagulant. So because warfarin has a slow onset of action, it may take about 5 to 10 days before the owner is within range. And the I know she measured just before the patient takes. Then it starts to the door there for once the owners and range. We start the treatment, and you saw the treatment with your next one, the other way of doing it, which is not really my preferred way. But it's something that you could do what the patient is in hospital. You stopped the door after immediately, and you start therapeutic enough expiring. Now they're critical not supporting. Whatever the normal, let the way heparin of choice is, you know, within your country's eso with a Nox apartment, be 1.5 mg per kilogram. Um, would be be would be the therapeutic range if the patient has got renal impairment that I mean, if it's less than 30 minutes committed, then you'll be 1 mg Picula ground, Um, once daily on, be a therapeutic dose of you're not supporting. So you start. The beauty cannot support in, and warfarin when you pick someone will be next year and then you stop the box of foreign once the warfarin is in range and that then that can be a standard procedure for patients who would just go on warfarin anyway. So it's something that people are more familiar with. So switching jobs. So this is a doctor, one toe warfarin. So for people taking 60 minutes permissive Adoxa bon, you would initially prescribed that about once daily with warfarin until the analyze range. People don't think that we're terms of the Doxil Violent didn't give the 15 rebounds once daily with your friends til the owners and range. So warfarin and the Adoxa bill and she would take it at the same time until the island or is that target. So that would be two or more than the the doxepin can be stopped. So is the little one a measure that I know the street times just prior to taking the day does the doxepin during the 1st 14 days off of having the treatment together. And when you're thinking about prescribing anticoagulants, this is something that the hemotologist I trained and that she had that she had put together. So but so, for example, if you look over here, they're actually not be used in those under 40 years of over 120 because of risk of overall under treatment. Dogs don't need to be monitored it, but it can mean that might absorption can be Ms. So you want to have a question in patients who got gastrectomy short bowel syndrome from high apple stoners. So you also want to take into account the liver function, whether they're pregnant, the interaction jokes. So the days old hit IV protease inhibitors I'm your drone to get your own for a family person. Ferritin is a big one, actually. So John's wort is also a big one. And as it's carbamazepine as well. Um, so, um, all right and the rest of them are more kind of tailor it to to the hospital where we were working, So that's fine. I think we've got time for a case study. However, I think we should move on to any questions at every anybody's got about atrial fibrilation or about the treatment for it as well. And if you feel like, is if you need to know a little bit up, but we live with more. But one of atrial fibulation are more than happy to do another session on sort of the different methodologies of How is Your Relation comes about if you haven't had that so other any questions. So the first question that someone asked it Waas What is the difference between atrial fibrilation and flatter? Okay, so the biggest thing that you'll notice with atrial flutter is actually going to be the presentation on the e. C. G. It's presented differently on the E C G episodes finally. So, as I said with atrial fibrilation, you'll notice that there will be an absence of the ways with atrial flutter. That's not always the case of the so the presentation. We'll look differently on the E Z e g and with atrial flutter. It's very, very slight in terms of how strong this contraction, actually at the house from their contractions. She happens as well. But the risks posed essentially are very similar, and therefore those people who do have atrial flutter would still be treated for of regulation or miss monitored for it as well. Thank you. Um, the next question is, why does mail in why two males in female? So why do you Why does it differ between males and females in atrial fibrilation and risk school. Okay, so let's just go back to the risk or in your okay, Here we go. So with females, I'm not particularly sure Why is that? They are higher risk off having clots. It may be that especially when the males are pregnant, they do have a high risk off putting. Um otherwise, I'm not particularly sure why they do have a higher risk. They just is the one thing where atrial fibrilation females get the females get the short, get the short end of the stick where is and everything else mail seem to have the short end of the stick. But this case, it's if you'd be that females do. Okay, Um, why do we start with by supper? Low than the other cardioselective got beat up blockers. I think it's more what what people feel comfortable with using myself for a while has always been first lying for even things like post semi and the evidence we know is there and for by supple, a swell eso people are comfortable using it. The evidence is there. We know that it controls the rate really well and people respond very well to it. So that's why we tend to use by supple all over the over the others with the others. You make it some better activity. Excellent that you happening in the lungs. But you can do with my softball two. And you do have to be cautious in settling in asthmatics. But that's predominantly wide by sample is sort of the preferred choice, but it is, um, largely most colleges collective. Um, the next question is why cont stop dabigatran be not be added to a dose. That box eso we will recover that question already. So on the next one was other any country introductions to by supper a little. And if so, what are the other options If there is a first line off a F treatment? Yeah, so as I mentioned, it would be more of an asthma eso if asthma was a concern. And you know that is documented, that the patient has reacted badly to buy Stop it all. Then you may want to consider something like digoxin in those patients. And yes, you may want to consider digoxin the patients, or you might want to try a different meter blocker. There's different. Physicians can respond differently to different meter blockers, so I normally they'll try maybe two or three beat blockers before they decide. Actually, let's go onto using the digoxin what they might do, a very low dose. So by stopping all that, they can tolerate it and then they can add in the diet drops in to then, uh, then control the rate on last question. Waas this clock cause A for a course clot formation. A. Of course, this confirmation, and this is why it's huge. It's such a massive driving factor because after somebody has actually had a stroke, the cost off, taking care of them in the community to the, you know, to be to the hospitals and everything like that. Costco Massive e. So the point off trying to detect a trough regulation is to preserve the quality of life for the patient and to make sure that you know the cost. Don't go up for the patient having somebody to take care of thumb so on. But you know badly you want to prevent that stroke from happening, so prevention is better than you call. So don't forget there are so many factors that even determine why people can have atrial fibulation. It can happen randomly. It can happen because you're obese. It can happen because you know you, you you're you're diabetic. You drink lots of coffee. You know, a lot of the sort of sort of factors can come into us to why patients could even get atrial fibrillation's well. And that's why the prevention is always better than think you're if you can see that the patient is hypertensive. If you can see that the patient has got their diabetes or on the risk or off diabetes, you want a net all of that in the butt to remember when I was talking about hypertension. If you get your hypertension under control, you make those lifestyle changes. You get your BP down, you're gonna prevent patients from having stroke from having you know the possibility of of, AH, risk factor for diabetes. You're preventing all of those things from happening. See if you can see the patient is on the eyes on the cost off. Even possibly having these risks have that conversation with the patient well, changing their lifestyle, being more active and preventing, you know, the possible risk of atrial fibrilation from happening Because, say, for example, you might be the best doctor in the world. That patient might not come to see you for five years. All of a sudden, they got a stroke because haven't come to see you in five years. No reason of pulse. Check on. Um, so every opportunity always do a pulse. Check to see if the patient has got an irregular pulse. So normally you're positive. Bum, bum, bum bum. You're looking for something that's gonna go bum bum, bum, bum, bum, bum bum. The that will tell me Incident. There's something not right with the patient will come up to any CG and in fact, taking a portable d c G devices now alive. Court. You may have heard of it. Essentially, it's a portable E c g, and you don't you can download the APP scorecard. Here. I've got one. My up one myself. On day, it's cardio up, and that's that's when it's sort of looked like stone if you can see you. But essentially, you put 22 fingers on the device and the new for the device. Want your leg on or your uncle on your left hand side and then it does a 60 e c g for you a while you can get the A life coach is single the CGM else topical little from relation. But it will tell you whether the patient atrial fibrilation or not. You see the E c g, which can Then we sent the can that can be sent to the doctor or the hospital. They This patient has got a trickle relation That's with them up to a B C D. Let's confirmed that the atrial fibrilation on. Then you start them on by Sapporo literally that rate control, if they're already between 60 and 70 and they may not need the direct control, the pulse is that. And then you start the one on coagulation. There is a couple more questions. What was How do you decide to choose between these three sevens between the three, Which three of the the anticoagulant? Yeah, uh but so the things you need to consider is decay. Can't the patient is a patient? Lots of food. Does the patient eat food? Because rivaroxaban, for example, cannot be absorbed on an empty stomach? You have to have it with food. Otherwise, you're not gonna get the full efficacy. So if you know that the patient eats little, that's the liver over oxygen out the door. If you know that they had a previous year bleed rivaroxaban out the door and so is a doctor. But it's up the door as well. If you know that they've had a previous interplaying, your bleed picks about his up picks out the door. If you know that the if the relation is having compliance issues, but they got dusted box, you could give them a picks. A ban that's not an issue. Eso it also, you wanted to take into account what their kidney function is that's going to determine whether they can have it. There are other drugs out there taking that's going to determine which dark that they're going to go onto a swell. And again, it's about the patient choices Well, so you must explain all of these things to the patient. So when I asked him a patient wave notice that you know you've got you got atrial fibrilation. This increases your risk of stroke. You know there are a number of ducks which are available to you tell me what your lifestyle like, Do you? Do you? Did you have meals three times Time? Oh, yeah. Can you be where we can? Hey, Any other questions? Um, yes. Is there anything that might cause false create insurance, both creatinine clearance. Um, anything you can help. Also cramp in in you wish. You can only find in like body builders. Um, that's how you can sort of have that. Um, the difficulty with creatinine clearance tends to be when you got extremes of body weight and nobody's really come to a decision that hasn't been really very much clear guidance about whether you would how, Whether you need to consider adjusted body way or ideal body weight for the actual body weight. And this is very becomes, actually quite difficult on dear is very little guidance on it is also very little evidence on it. But we're kind of hoping with more resection well, really world data that comes out, we'll be able to make better decisions for patients. But at the moment, if there are extremes of body weight, I always use Well, they're what they're ideal Body weight should be still be the middle finger when you calculate on on MD Culp. Okay, Perfect. Thank you so much. Um, you know, Doctor, you you said fix a bon. You need to check a previous bleed, but I fix about causes intracranial bleed. So it it it had a GI bleed can use. Yes, it is a quick someone still contraindicated? No, no, it had a previous GI I be. Then you can give them that. This is a key thing. They are not contraindication. Okay, Even if you had a G, I believe they are not contraindicated. It means that you have to protect the patient from the possibility of it happening. You have to be careful with the wedding that you use as well. It's about risk rather than it being country indicated. There's not a contraindication that the patient has a hard A previous intracranial bleed is your duty as the doctor say to patients, there is a risk off intracranial bleeding. If you were to go on warfarin, the risk would be higher of interpreting a bleed. However, with apixaban, your risk of intracranial bleed would be lower. Um, but if that's a concern for you, we can give you rivaroxaban instead Have you had a G? I believe before. Yes. Okay. Your GOP might be high with warfarin. Would you prefer to go on the rivaroxaban of your picks up on the patient? Might say. Well, actually, the risk is going to be the same with the big risk. Well, me is going to be a stroke, but I prefer to have one today, and I know I have it with food. I'll go with the Riboveron. Even so, these sorts of things they have to be taken into consideration, as opposed to an absolute indication. Is that anything? Yeah, there's just one more question, if that's okay, um, why is creating clear and so important in determining renal function when there are other ways, it's the kidney filters out. So there are about three or four different ways to calculate cramping clearance, and different places in different countries may have different ways are calculating of calculating. Uh, there is no 100% way of knowing what patients absolute creatinine clearance actually is. Unless you get the patient to basically pee for 24 hours every time they need to, do you measure that urine and even then you may get some loss of urine, so you may not even have accurate reading in clearance. Then grand in clearance is important because it does tell you how your nephrons are working in your kidneys. How much of kidneys are? Actually I'm filtering Teo. So that's why I cracked Nin is actually can consider more cause that and it actually goes through your kidneys. That's why we're measuring the pregnant clearance. Okay, Perfect. I think that's all the questions. If anyone else has the question, please ask now. Always. I guess you read to go, Doctor. Thank you so much, Doctor. Haven't used a much never so much doctor. Thanks for your time. It is any topics that you want me to cover as well. And, Buster cardiology really come to the drugs or anything like that. Please. You tell the organizes, and then I can kind of sort out for the next section. A zoo? Well, okay. Thank you very much. Take everybody