Atrial Fibrillation
Statistics



1.5% of people over 65 have AF
5x increased risk of stroke
25% all strokes in elderly are caused by AF
So……Time for some NICE guidelines!
Diagnosis
ECG on all pts where AF suspected because of
irregular pulse, regardless of whether or not they
have symptoms.
 BMJ study in 2007 – ECG not a good screening test
for AF, would miss 20% cases.
A good Hx and pulse check is more effective.

Paroxysmal AF not detected on routine ECG:
24h ambulatory if ?asymptomatic episodes or <24h
apart
Event recorder if >24h apart
Management






Acutely unwell – Admit
Further Ix for causative factors, including
?echo
Rate V Rhythm control
Thromboprophylaxis
Referral
Driving
Who needs an Echo?




Young pts
If considering rhythm control (electricity or
drugs)
Possible structural heart disease (murmur,
failure) – choice of antiarrhythmic agent.
As part of risk assessment for stroke in pts
where need evidence of LV dysfunction or
valvular heart disease.
Rate V Rhythm control first?

Rate
Over 65
Coronary artery disease
Unsuitable cardioversion
Unsuitable for
antiarrhythmics

Rhythm
Under 65
Lone AF
CCF
Secondary to treated trigger
Paroxysmal AF
Rhythm control – electricity and
drugs

Acute AF < 48h duration – speak to Medics about Electrical or
Pharmacological (amiodarone, flecainide) cardioversion.
Heparinize at presentation.
No anticoag necessary if maintain SR after.
AF >48h – Warfarin 3 weeks before (INR 2.5) or TOE.
If high R of AF recurrence then pre-treat with 4 weeks+ of
amiodarone or sotalol
Warfarin for 4 weeks after procedure, or long term if High R of
stroke or Recurrence, eg: AF >12m, enlarged LA, prev
recurrence.
Assess for need of long term antiarrhythmics….

Post Cardioversion




Consider antiarrythmic in anyone converted to SR
who did not have a corrected precipitant eg: chest
infection. (Beta blocker first line).
Follow up at 1m and 6m to check still in SR.
If SR at 6m then discharge back to GP.
If relapse, then re-evaluate need for rate V rhythm
control.
Rate Control
Beta Blocker or
Rate Limiting Calcium Antagonist
(diltiazem, verapamil)
Need better control normal activities (<110)
Need better control during exercise (<220-age)
RLCA with Digoxin
BBlocker OR RLCA
with Digoxin
Further rate control needed
Refer or Other drugs eg: amiodarone
Paroxysmal AF
Thromboprophylaxis as appropriate

?Suitable for “Pill in Pocket” :
One off dose of oral antiarrythmic to abort attack eg:flecainide
Criteria:
1.
No LV dysfunction/ valvular or IHD
2.
Infreq symptomatic episodes of AF
3.
SBP>100mmHg, Resting HR >70bpm
4.
Understand how and when to take medication

If unsuitable start standard BBlocker.

Try sotalol, amiodarone or flecainide if Rx fails, then refer.

Thromboprophylaxis
Paroxysmal, Permanent or Persistent AF
Assess Stroke/ Thromboembolism Risk
High
Prev isch CVA/ TIA/ TE event
>75 with HT, DM, Vasc dis
Echo evidence of LV dysf, failure,
or valve disease
Warfarin (INR 2.5)
(Aspirin if contraindic)
Moderate
>65 with no High RFs
<75 with HT, DM,
Vasc disease
Aspirin or Warfarin
Low
<65 with
no mod or high RFs
Aspirin 75-300mg/d
Referral for Specialist Intervention




Eg: Pacemaker, AV junction catheter ablation,
atrial defibrillators
Failed pharmacological Rx
Lone AF
ECG evidence of underlying pharmacological
disorder eg: WPW
AF and Driving
Gp 1
Must cease if incapacitated
by AF.
Permitted if cause ID’d and
controlled for 4 weeks.
No need to notify DVLA
unless
distracting/disabling Sx

Gp 2
Disqualifies if has caused
or is likely to cause
incapacity.
May be permitted when:
Controlled for 3/12
LV ejection fraction ≥0.4
No other disqualifying
condition.

Any Questions