Atrial Fibrillation Service Jayne Woolley Arrhythmia Specialist Nurse Royal Glamorgan Hospital.

Atrial Fibrillation Service

Jayne WoolleyArrhythmia Specialist NurseRoyal Glamorgan Hospital

Atrial Fibrillation Service

• In-patient referrals for New onset/Incidental finding AF – Advice and support to

medical team– Provision of patient

information and counselling

– Weekly AF MDT meeting– Follow-up clinics– Dronedarone – monthly

monitoring– Anticoagulation/NOAC

counselling initiation

Atrial fibrillation Service

• Both Rate/Rhythm control need :

Stroke risk assessment

CHADS2 – 0/1 reassess risk

CHA2DS2VASc score

1 anticoagulation to be considered 2 anticoagulation recommended

Atrial Fibrillation Service

• HASBLED score Hypertennsion (systolic > 160mmHG) 1 point Abnormal renal/liver function (chronic dialysis/transplantation, serum creatinine >200mmol/L chronic hepatic disease, bilirubin 2 x upper limit alkaline phosphatase 3 x upper limit 1 point each Stroke 1 point Bleeding 1 point previous bleeding history, anaemia etc Liable INR’s 1 point < 60% in theraputic range, unstable high INRs Elderly > 65yrs of age 1 point Drugs/Alcohol concomitant use of drugs , antiplatelet agents, alcohol abuse 1 point eachSCORE OF >3 HIGH RISK

Atrial Fibrillation Service• NOAC s for stroke prevention in adults with non-valvular AF with 1 or more risk factors:• Stroke/TIA/Systemic embolism• Symptomatic heart failure (NYHA) class >2 • Left ventricular failure, ejection fraction <40% • Age >75 yrs• Age >65 plus one of the following:•Diabetes mellitus, coronary artery disease or hypertension

Dabigatran, Apixaban and Rivaroxaban

Pros: Cons: Lower intercranial haemorrhage No known reversible agentRapid onset/short half life No monitoring No monitoring Heartburn/bloating/diarrhoeaNo food restrictions 100% compliance No alcohol restrictions Less drug interactions

Atrial Fibrillation Service

• Elective cardioversion Receive referrals

– Arrange anticoagulation and required investigations

– Recording weekly INR results (warfarin)

– Pre-assessment clinics– If on NOAC declaration is

signed by patient – Cardioversion procedure– 1 + 6 month follow-up

clinics

Atrial Fibrillation Service

• Elective cardioversion every 4 weeks

5-6 patients per list 13 currently waiting

at least 2 extra lists per year

Min4 Weeks

Max12 Weeks

Longer if subtheraputic INR

Waiting Times for Cardioversion

Atrial Fibrillation Service

Cardioversion April 2013-April 2014

88 patients listed 2 extras lists

82 successful - 93%

6 unsuccessful on the day - 7% (rounded up) max 3 shocks delivered, AF in theatre

Cancellations and Deferred PatientsApril 2013 – April 2014

• Cancellationso 5 – SR on workup/Pre-assessment

• Deferredo 2 – raised TSH (above 10)

o 12 – low INR

Atrial Fibrillation Service• Pre/Post cardioversion Weekly INRs 3 weeks before Preferred range 2.5 to 3.0 (reduced risk of stroke at higher level) if INR below 2 in the 3 weeks then they are cancelled

Weekly INRs 4 weeks post cardioversion Preferred range 2.5 to 3.0 (reduced risk of stroke at higher level)ESC and NICE state that anticoagulation should continue and not be interrupted for minimum of 4 weeks post cardioversion

Thromboembolic complications of direct cardioversion are generally related to inadequate intensity of anticoagulation. The INR at the time of conversion is very important. Anticoagulation is necessary for the conversion of atrial flutter as it is for atrial fibrillation. The INR should be 2.5 or more at the time of cardioversion of any atrial arrhythmia that has lasted for more than 2 days. J Am Coll Cardiol 2002

Thank You!