Atrial Fibrillation Service
Jayne Woolley
Arrhythmia Specialist Nurse
Royal 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 each
SCORE 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:
Lower intercranial haemorrhage
Rapid onset/short half life
No monitoring
No food restrictions
No alcohol restrictions
Less drug interactions
Cons:
No known reversible agent
No monitoring
Heartburn/bloating/diarrhoea
100% compliance
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
Waiting Times for Cardioversion
Min
4 Weeks
Max
12 Weeks
Longer if subtheraputic
INR
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 Patients
April 2013 – April 2014
•
Cancellations
o
•
5 – SR on workup/Pre-assessment
Deferred
o
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!