Download atrial fibrillation atrial flutter

ATRIAL FIBRILLATION
Kay Abbott CNS Arrhythmia
WHAT IS ATRIAL
FIBRILLATION?
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AF is the most common cardiac arrhythmia
1.2million patients diagnosed in UK
200,000 new AF patients diagnosed
annually
575,000 hospital admissions per year (1%
of NHS Budget annually)
1 in 4 stroke patients admitted in AF
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Atrial fibrillation Association (January 2009)
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Pathology
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Chaotic electrical activity develops within
the upper chambers of the heart (Atria) and
completely takes over from SA node
Atria no longer beat in an organised way
and pump less efficiently
Some impulses will be stopped by the AV
node but ventricles will beat irregularly and
possibly rapidly.
Sinus Rhythm
S
Atrial Fibrillation
S
AV
AV
Causes
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High Blood Pressure
Coronary Heart Disease
Mitral valve disease (?Rheumatic Heart disease, Infection)
Congenital heart disease
Pneumonia
Lung Cancer
Pulmonary embolism
Overactive thyroid
Carbon monoxide poisoning
Substance abuse (drugs, alcohol)
Old age
Symptoms of A.F.
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Palpitations
Shortness of Breath
Chest Discomfort
Light Headedness/fainting
Fatigue
NO SYMPTOMS AT ALL
ECG IN ATRIAL FIBRILLATION
The signals causing the beating of the ventricles (black arrows) are
irregular and a little rapid; the signals picked up from the fibrillating atrium
(red arrows) are very rapid and cause only an irregular ripple effect on the
baseline of the trace.
TYPES OF ATRIAL FIBRILLATION
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PAROXYSMAL AF –
multiple episodes of AF that cease
within 7 days with no treatment
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PERSISTENT AF -
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LONGSTANDING AF –
episodes lasting longer than 7 days
or less than 7 days with treatment
a one year duration
continuous AF of more than
ATRIAL FLUTTER
What is Atrial Flutter
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Similar to Atrial Fibrillation but has some
important differences
Impulse originates in the right atrium
(usually) and the atria beat very quickly and
regularly at around 300 beats per minutes
taking over from the sinus node
AV node will not conduct all of these beats
to the ventricles but allows every 2nd, 3rd or
4th beat through.
Gives a regular ventricular heart rate of
either 150bpm; 100bpm or 75 bpm.
Causes of Atrial Flutter
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Share similar causes as Atrial Fibrillation
More common in patients who have history of previous heart disease
Men twice as more likely to suffer than women
Often no one singular cause but a number of factors that increase the
likelihood :
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High Blood Pressure
Ischaemic Heart disease
Heart Valve Problems
Cardiomyopathy
Pneumonia
Cardiac Surgery
Pericarditis
Overactive thyroid
COPD
Excess Alcohol
Pulmonary embolism
Atrial Flutter 1 impulse allowed through AV node
Sinus Rhythm
S
Atrial impulse rate 300 divided by one impulse
allowed through the AV node gives a Ventricular
heart rate on the ECG of 75 bpm
S
AV
AV
What would ventricular rate be if 2 impulses allowed through?
What would ventricular rate be if 3 impulses allowed through?
Atrial Flutter
The signals causing the beating of the ventricles (black arrows)
are regular the signals picked up from the fluttering atrium
(red arrows) are very rapid at a rate of approx 300 bpm and
cause a saw-tooth appearance on the baseline of the trace.
RISKS OF ATRIAL FIBRILLATION /
ATRIAL FLUTTER
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Increased risk of stroke as blood in
atria becomes stagnant which in turn
increases risk of clot formation
If rate not controlled then risk of clot
formation higher and can also (in
extreme cases) lead to heart muscle
damage leading to heart failure
TREATMENTS
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Drug Treatments:
Stroke Prevention - Warfarin or Aspirin*
Rate Control/Anti-Arrhythmic – Beta Blocker, Calcium Channel Blocker, Flecainide,
Digoxin and/or Amiodarone
Non Drug Treatments:
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Cardioversion
Ablation
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CHADS2*
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Congestive cardiac failure 1
Hypertension
1
Age
1
Diabetes
1
Stroke/TIA
2
CHA2DS2VASc Score
Congestive Cardiac Failure 1
Hypertension
1
Age>75
2
Diabetes
1
Stroke/TIA
2
Vascular
1
Age>65
1
Sex Category
1
RAAF SERVICE
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Referrals from Hospital/GP/A&E
ECG enclosed confirming AF
Rapid Warfarin initiation
Tests/OPD arranged
Treatment
Follow up for 6 months
Referring Algorithm [care pathway] for all Patients Presenting with Atrial Fibrillation/Flutter
ALL BOXES MUST BE COMPLETED OR REFERRAL WILL BE RETURNED DELAYING TREATMENT
ECG must be enclosed confirming AF
New Onset AF less than 1 year? Yes/No
Unknown Onset – Symptomatic Yes/No
Add patient to AF Register [for Primary Care]
Unknown Onset – Asymptomatic Yes/No
Onset of AF longer than 1 year
Yes/No
What is the patient’s heart rate?
bpm
Target Rate Control = 60–80 bpm at rest
1st Line: Beta Blockers - 2nd Line: Diltiazem/Verapamil - Digoxin = 1st line for Sedentary patients
ANTI-COAGULATION – Please inform patient of referral for Warfarin Therapy
Prompt anticoagulation reduces the risk of systemic thromboembolism.
CHADS2 SCORE ……………….
LIST OF CONTRAINDICATIONS TO ANTICOAGULANT THERAPY:
- Active Bleeding
- Non-Compliance
- Active Peptic Ulcer
- Oesophageal Varices
- Bacterial Endocarditis
- Patient Choice
- Clotting Disorder
- Pregnancy/Breast
Feeding
- Dementia (mmse<20)
- Severe Hepatic Disease
- Excessive Alcohol Intake (greater than 2-3
- Severe Hypertension >180/110
units per day for women, 3-4 for men)
- Significant Renal Impairment (Creatinine
clearance
- History of Repeated Falls
<10ml/min)
- Inflammatory Bowel Disease
- Within 24 Hours of Surgery
Please sign below to confirm that there are no contraindications to long term anticoagulation. Upon receiving a signed form the RAAF
service will automatically forward it to the anticoagulant clinic for early appointment.
Name and Signature………………………………………………………Date………………………….
Oral anticoagulation should be initiated with a target INR of 2-3 and continued until further notice.
A SIGNED FORM CONSTITUTES A REFERRAL FOR WARFARIN, THEREFORE THE PATIENT SHOULD BE COUNSELLED AS
TO THE MERITS OF INITIATION OF WARFARIN AND THE CLINICAL BENEFITS/RISKS VERSUS ALTERNATIVE TREATMENTS
BY THE REFERRING CLINICAL TEAM
REFERRER to arrange following BLOOD TESTS:
- Full Blood Count
- Urea & Electrolytes
Tests
Date tests requested: ……………………………..
- Liver Function Tests
- Thyroid Function
Patient Name:
Unit No:
NHS No:
Referrer Name:
GP/Hospital:
Patient Address:
Date of Birth:
Referrer Contact Details:
PLEASE FAX THIS FORM TO RAAF SERVICE, SOUTHEND HOSPITAL
FAX NO. 01702 385965 TEL. NO. 01702 435555 ext 6078
Thank You
Any Questions