ATRIAL FIBRILLATION

CLINICAL APPROACH
AF WORKSHOP 2014

PRINCIPLES OF AF MANAGEMENT

(1) Rate control. (2) Prevention of thromboembolism. (3) Optimal management of etiology concomitant disease & complications. (4) Symptom relief. (5) Correction of rhythm disturbance.

CLINICAL APPROACH
CLINICAL HISTORY EXAMINATION RELEVANT INVESTIGATION DEFINE TYPE OF AF STRATIFY FOR STROKE PREVENTION STRATIFY BLEEDING RISK CONTROL RATE TREAT CAUSES/COMPLICATIONS IDENTIFY & CLOSE MONITOR HIGH RISK PT

CLINICAL HISTORY

Acutely unwell : unstable Symptomatic :

- Dyspnoea
- Palpitation - Lethargy - Dizziness - Syncope - Chest pain/discomfort

Associated condition or complications : - Heart failure, - ACS - Thyrotoxicosis, - Stroke - SA node dysfunction Opportunistic : - Asymptomatic - Incidental - Non specific symptoms

STRATIFY SYMPTOMS

PHYSICAL EXAMINATION

BP, HR : manual,pulse check

CVS/RESP/CNS/THYROID etc

RELEVANT INVESTIGATIONS
12 lead ECG : confirm diagnosis & rate TRANSTHORACIC ECHOCARDIOGRAPHY

- valvular vs non valvular vs structural lesion

- LV function, LA size - intramural clot - LVH etc

RFT/LFT/FBS/RBS/COAGULATION/TFT /LIPIDS etc CXR

DEFINE TYPE OF AF

VALVULAR AF : - valvular - rheumatic heart disease - prosthetic valves

NON VALVULAR AF

STRATIFY FOR STROKE PREVENTION

VALVULAR AF - ANTICOAGULANT

NON VALVULAR AF DO CHADS2 or CHA2DS2VASc score - ANTICOAGULANT or - ANTIPLATELET or - NONE

* Heart failure or LVEF 40%

CHADS2 SCORE
0 1 2

ANTITHROMBOTIC THERAPY
ASPIRIN OR none ORAL ANTICOAGULANT or aspirin ORAL ANTICOAGULANT

CHA2DS2-VASc SCORE
*

CHA2DS2-VASc score 0 1 2

antithrombotic therapy none or aspirin oral anticoagulant or aspirin oral anticoagulant * LVEF 40%

Vascular disease : MI, PVD, Aortic plaque

WHICH SCORING SYSTEM ?????

CHADSVASc provides a more accurate estimation of risk

THE BEST APPROACH

DO CHA2DS2-VASc SCORE FROM THE START

DO CHADS2 SCORE FIRST IF SCORE : 0 OR 1 DO CHA2DS2-VASc SCORE

STRATIFY BLEEDING RISK- HAS-BLED SCORE

3points: HIGH RISK

CONTROL RATE
PRIORITY FIRST IS RATE CONTROL PERSISTENT & PERMANENT AF- RATE CONTROL PAROXYSMAL AF - NO RX - RATE CONTROL - RHYTHM CONTROL CHOOSE BEST DRUG SET VENTRICULAR RESPONSE RATE

TREAT
REVERSIBLE CAUSES UNDERLYING PERPETUATING CONDITION COMPLICATIONS ASSOCIATED CONDITIONS

IDENTIFY & CLOSE MONITOR HIGH RISK PT

APPROACH IN STABLE , ASYMPTOMATIC / MINIMAL SYMPTOMS AF

Clinical Hx, Examination

ECG, Echo, CXR, bloods TFT, RFT,LFT,LIPIDS, FBS etc

Define- type of AF

Stratify : - risk of stroke ( valvular or CHADS2 or CHA2DS2VASc score ) - risk of bleeding (HAS-BLED score )

RX- Rate control first & anticoagulant as indicated Treat causes, ppt , complications , asstd conditions

Identify & close monitor high risk pt

APPROACH IN STABLE , SYMPTOMATIC AF

Clinical Hx, Examination

ECG, Echo, CXR, bloods TFT, RFT,LFT,LIPIDS, FBS etc

Define- type of AF RX- Rate control first & complications

Stratify : - risk of stroke (valvular or CHADS2 or CHA2DS2VASc score ) - risk of bleeding (HAS-BLED score )

RX- anticoagulant as indicated Treat causes, ppt , asstd conditions Identify & close monitor high risk pt

APPROACH IN UNSTABLE AF

Quick : Clinical Hx, Examination

RX- Cardioversion & IV heparin / LMWH

ECG, Echo, CXR, bloods TFT, RFT,LFT,LIPIDS, FBS etc

Define- type of AF
Stratify : - risk of stroke (valvular or CHADS2 or CHA2DS2VASc score ) - risk of bleeding (HAS-BLED score )

RX- anticoagulant ,rate or rhythm control as indicated Treat causes, ppt , complications , asstd conditions Identify & close monitor high risk pt