Download AF1 - NHS Wales

Atrial Fibrillation
RACHEAL JAMES
HEART RHYTHM
SPECIALIST NURSE
UHW
The Role of the Heart Rhythm Specialist Nurse
 It is now widely recognised within our trust that
the skills and expertise the Heart Rhythm
Specialist Nurses bring to arrhythmia services are
extremely valuable.
 The role of the specialist arrhythmia nurse is
diverse and varies dependent on local service
needs
 Roles include caring for patients with Atrial
Fibrillation, Device therapy (ICD or CRT-D),
syncope and screening for SCD relatives
Journey of Heart Rhythm Specialist Nurse
 Qualified as Registered Nurse October 1996
 9 Years Acute Cardiology Experience on Coronary
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Care Unit at University Hospital of Wales
3 Years Experience on the Cardiac Day Case Unit –
Cardiology and Electrophysiology intervention
4 Years Heart Rhythm Specialist Nurse
Currently attending the MSc “Advanced Programme”
at Cardiff University
Independent Prescriber
MSc Arrhythmia Management Module
Nurse-led
Syncope
Clinic
AF +DCCV
Service
Heart Rhythm
Specialist
Nurse
ICD + CRT-D
education
and support
Catheter
Ablation
Atrial Fibrillation
• Atrial Fibrillation is caused by multiple micro re-
entry circuit within the atrial tissue (200-300 per
minute) which results in chaotic atrial activity. It is
manifested on ECG by absent “P” waves, an
irregular baseline, and irregularly irregular
ventricular complexes .
Atrial Fibrillation
Risks factors for Atrial Fibrillation
 Hypertension
 Coronary artery disease
 Heart Failure
 Hyperthyroidism
 Rheumatic heart disease-valvular defects
 Obesity
 Alcohol
Atrial Fibrillation
Quick Check: Atrial Fibrillation
Rate
Rhythm
Ventricular
< 100 bpm controlled
Irregular
Atrial
< 350/minute
Absent
P-R Interval
Absent due to fibrillation
waves
QRS Complex
Normal
Atrial Fibrillation
Atrial Fibrillation
Atrial Flutter
Quick Check: Atrial Flutter
Rate
Rhythm
Ventricular
Dependent on
conduction ratio
Regular*
Atrial
> 300/minute
Regular
P-R Interval
Absent due to flutter
waves
QRS Complex
Normal
*A variable atrial flutter will cause the rhythm to become irregular.
Atrial Flutter
Atrial Flutter
Prevalence of Atrial Fibrillation
Atrial fibrillation (AF) is the most common
cardiac arrhythmia, affecting 1-2% of the general
population, rising to 10% in the over 75-year-olds.
 Cardiff 1.21% and Carmarthenshire 2.02%
detected cases of AF in 2007
 AF is becoming an increasingly common
condition in our aging population and is a
significant cause of hospital admissions,
morbidity and mortality.
 Significant financial burden for the NHS
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Strategies for the management of AF
Stroke
prevention
• Risk stratify: CHA2DS2VAS c or CHADS2 scores
• Anticoagulants (novel Warfarin or new agents
Dabigatran)
• Underutilized
Rate
• Adequate rate control defined as achievement of
arbitrary heart rate target at rest and exercise
control
Rhythm
control
• Revert to Sinus Rhythm
• DCCV or Catheter Ablation
• Efficacy defined as “freedom from AF”
Types of Atrial Fibrillation
Paroxysmal Atrial Fibrillation
Episodes that stop within 7 days without treatment.
Persistent Atrial Fibrillation
Episodes lasting longer than 7 days, when not treated.
Permanent Atrial Fibrillation
AF which has lasted for more than one year.
AF Increases the Risk of Morbidity
•Atrial Fibrillation patients have a near
5-fold increased risk of stroke
•33% of acute strokes in elderly
population are related to AF
•12% risk of recurrence
after initial stroke
Risk Stratify: CHADS2 score
CHADS2
Score / 6
Congestive Heart
Failure
Hypertension (140/90
mmhg)
Age > 75 years
Diabetic
Stroke or previous
TIA
1 point
1 point
1 point
1 point
2 point
Stroke Risk
CHADS2 score
1 Moderate Risk
2 High Risk(Warfarin)
3
4
5
6
Annual Stroke Risk
2.8
4.0
5.9
8.5
12.5
18.2
Novel Anticoagulation Agents
 Warfarin therapy: 1 mg, 3 mg & 5mg tablets
 Requires regular monitoring with blood tests:
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International National Range (INR)
Safe to take if therapeutic ranges are maintained: 2.0
– 3.0 with target 2.5
Bleeding risk
Drug-to-drug interactions
Food interactions
New Anticoagulation agent
 Prevention of stroke in adults with non-valvular
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atrial fibrillation with 1 or more risk factors:Previous stroke, TIA or systemic embolism (SEE)
Left ventricular ejection fraction (LVEF) <40%
Symptomatic heart failure (NYHA) class >2
Age> 75 years
Age >65 years associated with one of the following:
diabetes mellitus, coronary artery disease or
hypertension
New Anticoagulation Agents
 Dabigatran: 110mg & 150mg (BD)
 Rapid onset of action: 2 hours
 No dietary restrictions
 No requirement for routine coagulation (INR)
monitoring
 Main side-effect: Dyspepsia
Symptoms of Atrial Fibrillation
Rate Control: Slow ventricular rate
 The latest ESC guidelines state that it is reasonable to
initiate treatment with a rate control protocol aimed at a
resting heart rate of <110 beats per minute.
 When symptoms persist a stricter rate control strategy
should aim at achieving a resting heart rate <80 beats
per minute and a heart rate during moderate exercise
<110 beats per minute.
 First-line therapies for pharmacological control of heart
rate include beta-blockers, calcium channel blockers and
digitalis, which can be used either alone or in
combination
 Unfortunately many of the side-effects from antiarrhythmic medications are intolerable
Rhythm Control: Restore Sinus Rhythm
 Direct Current Cardioversion (DCCV): Synchronized
electrical cardioversion using biphasic defibrillator
 A synchronized shock via 2 pads with selected
amount of electric current over a predefined number
of milliseconds at the optimal moment in the cardiac
cycle.
• Timing the shock to the R wave prevents the delivery
of the shock during the vulnerable period (or relative
refractory period) R wave of the QRS complex on the
ECG.
• Reduce risk of inducing Ventricular Fibrillation
Rhythm Control: Restore Sinus Rhythm
• Heart Rhythm Specialist Nurse accepts direct
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referrals for DCCV service – suitability?????
Currently 45 patients on waiting list
3-4 DCCV each week (170-180 a year)
Initiates anticoagulation – Warfarin Therapy and
coordinates therapeutic ranges pre DCCV
Direct contact in symptoms change or relapse back
into AF post PVI or DCCV
Pulmonary Vein Isolation
 Performed in CCR
 Consciousness Sedation
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or occasional GA
Access via femoral
punctures
To access left atrium
“Transeptal puncture”
via right atrium
Mapping and Ablation
catheter placed in Left
Atrium
Continual IV Heparin
Duration 3-7 hours
Pulmonary Vein Isolation Ablation
Pulmonary Vein Isolation at UHW 2012
54 Male
71
procedures
40 PAF
17 Female
31
Persistent
AF
Success rates of PVI procedure at UHW
62 patients had Sinus
Rhythm successfully restored
7 patients required DCCV
2 patients had procedure
aborted due to pain
Long term success rates at mean follow-up 7.2
months
Paroxysmal Atrial Fibrillation
National 80-85%
UHW 86%
Persistent Atrial Fibrillation
National 70-75%
UHW 54%
Re-do procedures to achieve SR
National 30-40%
UHW 7.5%
Pulmonary Vein Isolation
 Nurse-led clinic to provide education and support
regarding PVI procedure, risks involved and
medication therapy, especially Warfarin.
 Ensure INR levels are therapeutic for 3 weeks prior
to reduce Stroke risk- 0% at UHW
 Aid discharge planning when inpatient (stab-site,
therapeutic INR, Sinus Rhythm? DCCV?)
 Follow-up at Nurse-led clinic at 2 months, assess
atrial rhythm and symptoms post PVI
Pulmonary Vein Isolation
 Independent Prescriber to restart or titrate anti
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arrhythmic drugs if relapsed back into AF.
Arrange DCCV if relapsed into persistent AF
Direct access via telephone-anxious patients
awaiting a very complex procedure-lots of questions.
Recovery not always straightforward- prone to bouts
of AF post PVI-doesn’t mean PVI unsuccessful.
Main link between Consultant, GP, secretary and
patient.
Support from Arrhythmia Charities
British Heart Foundation & Atrial
Fibrillation Association
Raise Awareness of Atrial
Fibrillation
Arrhythmia Alliance (AA)
Provide education and support
for AF patients – information
sheets and leaflets
Annual “Know your pulse” at UHW 2011
Thank You
Any
Questions???