AF update October 2016 - healthlearningpartnership.co.ukhealthlearningpartnership.co.uk/uploads/20161012133301.pdf · AF update October 2016 Dr Edward Duncan MRCP PhD Consultant Cardiologist

AF update October 2016

Dr Edward Duncan MRCP PhD

Consultant Cardiologist & Electrophysiologist

Bristol Heart Institute

and Bristol Heart Rhythm Centre

Aspirin in Stroke

Prevention 18.6.14

Key message:

http://www.google.co.uk/url?q=http://wiki.erepublik.com/index.php/User:John_F_Baker/Grave_Template&sa=U&ei=DCDlUomQBeWK7AbnjoGAAg&ved=0CDIQ9QEwAg&sig2=OrbaNDPxxzMQ99-3wF9Eyw&usg=AFQjCNG5uf_okGJobBc7HdburAG199gOkg

Patterns of AF

Modified European Heart Rhythm Association symptom scale

ESC guidelines 2016

NICE:

ESC guidelines 2016

Anticoagulation in AF:

Atrialfibrillation.org.uk

http://www.preventaf-strokecrisis.org/calculator

NICE guidelines 2014

ESC guidelines 2016

What’s wrong with aspirin?

• 64% RR with warfarin (tough act to follow)

– (could be greater…many strokes occurred when INR < 2)

• 8 RCTs compared aspirin vs placebo (n=4876)

– 7 showed a non-significant stroke reduction

• 9 RCTs compared aspirin with warfarin; all showed inferiority

• “It’s safer than warfarin in the elderly, falls etc…”

• Birmingham AF Treatment of the Aged (BAFTA)

– Warfarin superior to aspirin (52%) in all strokes (fatal, disabling, ischaemic

or haemorrhagic)

– No difference in bleeding risk

• Warfarin vs Aspirin for Stroke Prevention in Octogenerians (WASPO)

– Warfarin superior to aspirin

– Significantly higher bleeding risk with aspirin (33% vs 6%)

What’s wrong with aspirin?

HAS-BLED

• HTN > 160mmHg

• Cr ≥ 200μmol/L

• Bil ×2

• AST ×3

• INR<60% in range

• Score ≥3 High Risk

Patterns of AF

Mechanism: Paroxysmal to persistent AF

Crandall M A et al. Mayo Clin Proc. 2009;84:643-662

Stroke risk in PAF vs PsAF

Management of typical atrial flutter

• Thromboembolic risk

• Ventricular rate control

• DC cardioversion

• Anti-arrhythmic drugs

• Catheter ablation

Management of typical atrial flutter

• Thromboembolic risk

• Ventricular rate control

• DC cardioversion

• Anti-arrhythmic drugs

• CATHETER ABLATION

Atrial Flutter

Flutter recurrence Fibrillation onset

NICE guidelines 2014

Management of the patient with AF

(my thought processes)

1) Thromboprophylaxis

2) Symptom control

3) LV protection

Decreasing

importance

• Rate vs Rhythm control

– If rate control:

• Betablocker, Diltiazem, Digoxin

• Pace and ablate

– If rhythm control:

• Oral anti-arrhythmic therapy

– Bisoprolol, Flecainide, Sotalol, Amiodarone

• (DCCV)

• Catheter ablation

Symptom control in AF

Choice of Anti-arrhythmic drug

REFER

Anti-arrhythmic drug or catheter ablation for rhythm control of AF

REFER

• All typical flutter patients

• Symptomatic patients with AF who fail 1 AAD

• Paroxysmal (PAF) > persistent (PsAF)

• PsAF < 1 years duration

or PsAF who maintain SR post DCCV

Who to refer for catheter ablation?

Ablation versus AAD

Wilber, D. J., C. Pappone, et al. (2010). "Comparison of antiarrhythmic drug therapy and radiofrequency catheter

ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial." Jama 303(4): 333-40.

Any questions?

• 75 year old man

• PMH Gout, HTN, CKD, PCI 2010

• BP check

• Irregular pulse

• ECG – AF 75bpm

• Mx?

• CHADSVASc

• Symptoms

• Echo and routine bloods

Scenario

• 60 year old woman

• Temporal arteritis, Ca Breast

• Oncology F/up OPA

• ECG – 80bpm, typical flutter

• Mx?

• CHADSVASc

• Symptoms


• Refer for Ablation

Scenario

• 80 year old man

• tAVR and grafts 2011

• SOB

• New AF 120bpm

• Mx?

• CHADSVASc?

• Symptoms?

• Rate control. Which drugs?

• Echo

• Refer?

• DCCV?

Scenario

• 4/12 post DCCV

• SR

• Vast improvement

• Meds review:

• Warfarin

• Bisoprolol

• ARB

• Statin

• What changes?

The same patient

• 53 year old man

• EtOH 35 units per week

• 3x A+E with AF

• Acutely DCCV or iv flecainide

• GP f/up for palpitations

• Mx?

• CHADSVASc

• Symptoms


• Medical therapy?

• ?refer

Scenario

• Arrhythmia hx

• PMH and Drug hx

• CHADSVASc score

• Symptoms

• Echo

• Bloods

The AF/flutter consultation

Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx

SVT AVNRT

AVRT

AT

Atrial flutter

AF PAF

PsAF

VT/VF Structural Heart dis


SVT AVNRT Ablation

AVRT

AT

Atrial flutter

AF PAF

PsAF



SVT AVNRT Ablation Ablation

AVRT

AT

Atrial flutter

AF PAF

PsAF



SVT AVNRT Ablation Ablation Conservative

AVRT

AT

Atrial flutter

AF PAF

PsAF




AVRT Ablation Ablation Conservative

AT Ablation Ablation Conservative

Atrial flutter

AF PAF

PsAF






Atrial flutter Ablation

AF PAF

PsAF






Atrial flutter Ablation Ablation Conservative

AF PAF

PsAF







AF PAF Medical

PsAF







AF PAF Medical Ablation

PsAF







AF PAF Medical Ablation PPM + node

PsAF








PsAF Medical

+/- DCCV








PsAF Medical

+/- DCCV Ablation








PsAF Medical

+/- DCCV Ablation PPM + node








PsAF Medical



Medical +/- ICD







PsAF Medical



Medical +/- ICD

Ablation Nil

AF update October 2016 - healthlearningpartnership.co.ukhealthlearningpartnership.co.uk/uploads/20161012133301.pdf · AF update October 2016 Dr Edward Duncan MRCP PhD Consultant Cardiologist

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