Atrial Fibrillation

Etiology Clinical Presentation, Diagnosis, Investigation Management Algorithm for Management of AF in the Out-Patient Setting

National Healthcare Group Adding Years of Healthy Life

Atrial Fibrillation
Background
Found in 10% of the population above 80 years old. Independent risk factor for ischaemic stroke Risk of stroke in AF patients 1.5% in the 50- to 59-year age group 23.5% in the 80- to 89-year age group. Antithrombotic therapy in AF patients significantly decreases the stroke risk.

Etiology
Hypertension Ischaemic heart disease Valvular Heart Disease Congestive heart failure Cardiomyopathy Pericarditis Thyrotoxicosis Chronic lung disease Wolff-Parkinson-White syndrome. Alcohol, caffeine, sympathomimetic drugs, hypoxia, hypoglycaemia, hypokalaemia and systemic infection may also induce AF.

Atrial Fibrillation - Etiology

AF-1

Atrial Fibrillation
Clinical Presentation
Asymptomatic significant proportion Palpitations Chest Pain CCF Hyperthyroidism Stroke

Diagnosis
Pulse = irregular in both rhythm and rate ECG = absence of P waves, irregular undulating baseline (AF waves) variable R-R interval Evidence of pre-excitation (eg. delta wave) and aberrant conduction (eg. wide QRS complexes) should also be sought.

Investigation
Stable patients with chronic AF who are not candidates for cardioversion may be managed in the out-patient setting. Apart from an ECG, serum electrolytes and thyroid function tests are recommended for these patients to exclude an underlying pathology. Many AF patients, however, require referral to the Emergency Department or direct hospital admission for urgent cardiac assessment and monitoring. They include: (1) Patients with serious acute underlying medical conditions, such as suspected myocardial ischaemic or infarction, or heart failure; (2) Patients who are symptomatic or present with impaired haemodynamic status as a result of their AF; (3) Patients with a fast ventricular response rate, or in whom pre-excitation through an accessory conduction pathway is suspected; (3) Patients who develop a complication of AF, such as an embolic stroke or a systemic embolic event; and (4) Patients with acute onset of AF within the preceeding 48 hours who are judged to be candidates for urgent cardioversion.

Atrial Fibrillation - Clinical Presentation, Diagnosis, Investigation

AF-2

Atrial Fibrillation
Management
The aims of management of AF include: 1) Control of ventricular rate; 2) Restoration and maintenance of sinus rhythm; and 3) Stroke prevention. 1) Control of ventricular rate Beta blockers (eg. propranolol, metoprolol, atenolol) Calcium antagonists (eg. diltiazem, verapemil) Digoxin in patients with LVF or heart failure All three groups of agents are contraindicated in AF associated with pre-excitation in Wolff-Parkinson-White syndrome. 2) Restoration and maintenance of sinus rhythm These aspects of management involve specialist knowledge and skills, and should be performed by cardiologists. 3) Stroke Prevention In a significant proportion of AF patients, long-term oral anticoagulation substantially reduces the risk of stroke. A risk stratification scheme derived from the results of multiple large-scale studies of primary and secondary stroke prevention trials in AF patients assist in determining the best antithrombotic therapy for the individual patient. However, because of the higher incidence of haemorrhagic strokes in the local population, together with the clinical impression among many physicians that the local elderly patients are more susceptible to the bleeding complications of warfarin, the following recommendations are moderated from established guidelines in the U.S.A. and UK. In particular, long-term warfarin therapy is only recommended for AF patients over the age of 75 years with the concomitant presence of another risk factor.

faster rate of onset and better control of exertion induced tachycardia then digoxin

Atrial Fibrillation - Management

AF-3

Atrial Fibrillation
High-risk factors Prior stroke/TIA/systemic embolism Prosthetic heart valve Rheumatic mitral valve disease Moderate-risk factors Age 75 years History of hypertension Congestive heart failure Diabetes mellitus Coronary artery disease Thyrotoxicosis Poor left ventricular function (demonstrated by TTE)
WARFARIN ASPIRIN

1 High Risk factor or 1 Moderate Risk Factors 1 Moderate risk factor < 75 years old with no risk factor

Paroxysmal AF should be treated as for patients with chronic AF. For patients who are contraindicated for warfarin (eg. significant bleeding or fall risks, active peptic ulcer disease, or patients unlikely to comply with the diet and monitoring regimens required in warfarin therapy), long-term antiplatelet therapy should be given instead.

Atrial Fibrillation - Management

AF-4

Atrial Fibrillation
INR Range
2.5 3.5 2.0-3.0 Mechanical valve (except bileaflet aortic mechanical valve) Rheumatic valve disease Prior stroke/TIA/systemic embolism 2 or more moderate risk factors Bileaflet aortic mechanical valve Frail elderly Increased risk of bleeding complications

1.8-2.5

Algorithm for Management of Atrial Fibrillation in the Out-Patient Setting

An algorithm for management of AF patients is outlined below, based on the above considerations. In case of any uncertainty, the family physician is always welcomed to contact the cardiologist or the neurologist on-call for further discussion and advice.

Atrial Fibrillation - Management

AF-5

Atrial Fibrillation
Algorithm for Management of AF in the Out-Patient Setting
(** Blood tests are not necessary if the patient is going to be seen at A&E or specialist clinic on the same day) Irregular Pulse 12 Lead ECG AF Confirmed Urea & Electrolytes** Thyroid Function Tests** Aspirin 300mg Stat, 100mg OM Consider Rate Control Unstable CV status Myocardial Ischaemia Stroke/Embolism To A & E immmediately Stable Known as Onset < 48hrs To A & E or same day Direct Access Clinic Stable Onset > 48hrs No Cardiac Assessment Cardiac Referral Stable Known Chronic AF Cardiac Assessment Manage in OPS Finalize Rate Control Medication Not AF

Moderate-risk factors
Age 75 years History of hypertension Congestive heart failure Poor left ventricular function (demonstrated by TTE) Diabetes mellitus Coronary artery disease Thyrotoxicosis

Assess Stroke Risk Previous TIA/Stroke/Embolism Mechanical Heart Valve/ Rheumatic MV 2 or more Moderate Risk Factors Warfarin INR 2.0-3.0 1 or less Moderate Risk Factor Aspirin or other anti-platelet agent AF-6

Atrial Fibrillation - Algorithm for Management of AF in the Out-Patient Setting

Atrial Fibrillation
References
Prystowsky EN et al (1996): Management of patients with atrial fibrillation. A statement for healthcare professionals from the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. Circulation 93:1262-1277. Albers GW et al (2001): Antithrombotic therapy in atrial fibrillation, Sixth ACCP Consensus Conference on Antithrombotic Therapy. Chest 119: 194S-206S. Gage BF et al (2001): Validation of clinical classification schemes for predicting stroke. Results from the national registry of atrial fibrillation. JAMA 285:2864-2870.

Atrial Fibrillation - References

AF-7