Atrial Fibrillation

Steve McGlynn
Specialist Principal Pharmacist (Cardiology),
Greater Glasgow and Clyde
Honorary Clinical Lecture,
University of Strathclyde
Some types of arrhythmia
 Supraventricular
 Sinus Nodal
 Sinus bradycardia
 Sinus tachycardia
 Sinus arrhythmia
 Atrial
 Atrial tachycardia
 Atrial flutter
 Atrial fibrillation
 AV Nodal
 AVNSVT
 Heart blocks
 Junctional
 Ventricular
 Escape rhythms
 Ventricular tachycardia
 Ventricular fibrillation
Atrial fibrillation
 A heart rhythm disorder (arrhythmia). It usually
involves a rapid heart rate, in which the upper heart
chambers (atria) are stimulated to contract in a very
disorganized and abnormal manner.

 A type of supraventricular tachyarrhythmia

 The most common arrhythmia

Aetiology
 Rheumatic heart disease  Thyrotoxicosis
 Coronary heart disease  Infection
(MI)  Alcohol abuse
 Hypertension  Pulmonary embolism
 Myopericarditis  Caffeine
 Hypertrophic  Exercise
cardiomyopathy
 Cardiac surgery
 Lone AF
NHS QIS Clinical Standards Audit 2010:
AF PREVALENCE IN SCOTLAND

NHS QIS Clinical Standards April 2010 - Heart Disease

Submitted Practices
NHS Board Residence (HB) Population with AF Percentage (%)
Population

Numerator Denominator
Ayrshire & Arran 1,512 112,292 1.3%
Dumfries & Galloway 483 29,581 1.6%
Fife 1,357 96,989 1.4%
Forth Valley 2,064 142,264 1.5%
Greater Glasgow & Clyde 9,625 673,305 1.4%
Highland 790 60,598 1.4%
Lanarkshire 1,700 129,339 1.3%
Lothian 1,354 98,918 1.3%
Orkney 69 4,189 1.4%
Shetland 138 9,849 1.6%
Tayside 237 12,617 1.4%
Western Isles 141 6,893 1.9%
SCOTLAND 19,470 1,376,834 1.4%
Classification
 New / Recent onset  Persistent
 < 48 hours  Non-self terminating
 Cardiovertable

 Paroxysmal  Permanent
 variable duration  Non-self terminating
 self terminating  Non-cardiovertable
Symptoms / Signs
 Breathlessness /  Irregularly irregular pulse
dyspnoea  Atrial rate
 Palpitations  300-600bpm
 Syncope / dizziness  Ventricular rate depends
on degree of AV block
 Chest discomfort
 120-160bpm
 Stroke / TIA
 Peripheral rate
 6 x risk of CVA slower (pulse deficit)
 2 x risk of death
 18 x risk of CVA if
rheumatic heart disease
Investigations
 Electrocardiogram (ECG)
 All patients
 May need ambulatory monitoring
 Transthoracic echocardiogram (TTE)
 Establish baseline
 Identify structural heart disease
 Risk stratification for anti-thrombotic therapy
 Transoesophogeal echocardiography (TOE)
 Further valve assessment
 If TTE inconclusive / difficult
Normal Sinus Rhythm
‘Fast’ AF
‘Slow’ AF
Investigations
 Electrocardiogram (ECG)
 All patients
 May need ambulatory monitoring
 Transthoracic echocardiogram (TTE)
 Baseline
 Structural heart disease
 Risk stratification for anti-thrombotic therapy
 Transoesophogeal echocardiography (TOE)
 Further valve assessment
 TTE inconclusive / difficult
Diagnosis

 Based on:

 ECG
 Presentation
 Response to treatment
Treatment objectives

 Rhythm / rate control

 Stroke prevention
Treatment strategies
 New / Recent onset  Persistent
 Cardioversion  Cardioversion
 Rhythm control  Rhythm control
 Peri-cardioversion
 Paroxysmal thromboprophylaxis
 Rate control or
cardioversion during  Permanent
paroxysm  Rate control
 Rhythm control if  Thromboprophylaxis
needed
Pharmacological Options
 Class Ic Anti-arrhythmics
 Flecainide / Propafenone
 Rhythm control
 May also be pro-arrhythmic

 Class II Anti-arrhythmics
 Beta-blockers
 Mainly rate control
 Control rate during exercise and at rest
 Generally first choice
 Choice depends on co-morbidities
 Class III Anti-arryhthmics
 Amiodarone / Dronedarone
 Mainly rhythm control
 May be pro-arrhythmic
 Concerns over toxicity

 Class IV Anti-arryhthmics
 Calcium channel blockers (verapamil / diltiazem only)
 Rate control only
 Alternative to beta-blockers if no heart failure

 Digoxin
 Rate control only
 Does not control rate during exercise
 Third choice unless others contra-indicated
Acute AF
Treatment will depend on:

 History of AF
 Time to presentation (<> 24 hours)
 Co-morbidities (CHD, CHF/LVSD etc)
 Likelihood of success (History)
 Rate Vs. Rhythm control

 Rhythm control not feasible or safe

 Beta-blocker
 Verapamil
 Digoxin (CHF)
 Rhythm control if possible and safe
 DC cardioversion (if possible)
 Amiodarone (CHD or CHF/LVSD)
 Flecainide (Paroxysmal AF)
Paroxymal AF
 Rhythm control*  Antithrombotic therapy as
 Beta-blocker per risk assessment
 Class 1c agent or sotalol  Aspirin 75-300mg
 warfarin to INR 2-3
 If CHD - sotalol
 See later
 If LVD: Amiodarone

 Dronedarone?
 Not if heart failure

*May be “Pill in the pocket”

Persistent AF
 Rhythm control  Antithrombotic therapy as
 Beta blocker per risk assessment
 No structural heart  Pre-cardioversion
disease: Class 1c* or thromboprophylaxis of at
sotalol least 3 weeks
 Structural heart
disease: amiodarone
 If rate control, as for
 Rate control permanent AF
 As for permanent AF

* not if CHD present

Permanent AF
 Beta blocker or  Antithrombotic therapy as per
 Calcium channel blocker risk assessment
and/or  Aspirin 75-300mg
 Digoxin  Warfarin to INR 2-3
 See later
 Amiodarone?
 Option if poor rate
control on above
 Dronedarone?
 Increased mortality
Stroke prevention
(non-rheumatic AF)
Stroke Risk Assessment
(CHADS2)
 C Chronic Heart Failure (1 point)
 H Hypertension (1 point)
 A Age > 75 years (1 point)
 D Diabetes (1 point)
 S Stroke, TIA or systemic embolisation (2 points)

 Score < 2: low risk, aspirin* or anticoagulant

 Score ≥ 2: high risk, anticoagulant indicated

*Evidence for aspirin is weak

Stroke Risk Assessment
(CHA2DS2VASc)
 Alternative to CHADS2

 C Chronic Heart Failure (1 point)

 H Hypertension (1 point)
 A Age > 75 years (2 points)
 D Diabetes (1 point)
 S Stroke, TIA or systemic embolisation (2 points)
 V vascular disease (1 point)
 A Age 65-74 years (1 point)
 Sc Sex category (1 point if female)

 Score ≥2 = High risk – anticoagulate unless

contraindicated
Bleeding Risk Assessment
(HAS-BLED)
 1 point each for:
 Hypertension
 Abnormal renal/liver function (1 for each)
 Stroke
 Bleeding history or predisposition
 Labile INR
 Elderly (age over 65)
 Drugs*/alcohol** concomitantly (1 for each)

*Drugs that increase bleeding, e.g. aspirin

** Alcohol excess
Anticoagulants
 Warfarin remains standard anticoagulant at present

 3 new oral anticoagulants

 Dabigatran (Direct thrombin inhibitor)
 Licensed by MHRA
 Approved by SMC
 Rivaroxiban (Factor Xa inhibitor)
 Licensed by MHRA
 Apixaban (Factor Xa inhibitor)

 Fixed doses
 No monitoring
 At least as effective as warfarin
 Safer than warfarin?
 Dabigatran capsules not stable outside of original blister
 Very difficult to reverse effect unlike warfarin
 Much more expensive (even allowing for INR costs)
 Place in therapy not clear yet
Dabigatran Consensus
NHS in Healthcare Improvement Scotland Working Group:
National consensus on dabigatran

The consensus statement states that:

 on balance of risks and benefits, warfarin remains the anticoagulant of

clinical choice for moderate or high risk atrial fibrillation patients (CHA2DS2-
VASc ≥ 2) with good INR control, and

 clinicians should consider prescribing dabigatran in patients with:

 poor INR control (less than 60% of time in INR range) despite evidence that
they are complying, or

 allergy to or intolerable side effects from coumarin anticoagulants.

 http://www.healthcareimprovementscotland.org/default.aspx?page=13900
Conclusions
 AF is a common condition.
 Patients may be unaware of its presence and are
therefore at risk of a stroke
 Effective treatment strategies exist to control
symptoms
 Effective treatment strategies exist to reduce the
risk of stroke
 Patient education and choice are central to
improving the likelihood of treatment success