Atrial Fibrillation Service Jayne Woolley Arrhythmia Specialist Nurse Royal Glamorgan Hospital This template can be used as a starter file to give updates for project milestones. Sections Sections can help to organize your slides or facilitate collaboration between multiple authors. On the Home tab, under Slides, click Section, and then click Add Section. Notes Use the Notes pane for delivery notes or to provide additional details for the audience. You can see these notes in Presenter View during your presentation. Keep in mind the font size (important for accessibility, visibility, videotaping, and online production) Coordinated colors Pay particular attention to the graphs, charts, and text boxes. Consider that attendees will print in black and white or grayscale. Run a test print to make sure your colors work when printed in pure black and white and grayscale. Graphics, tables, and graphs Keep it simple: If possible, use consistent, non-distracting styles and colors. Label all graphs and tables.

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: Cons: Lower intercranial haemorrhage No known reversible agent Rapid onset/short half life No monitoring No monitoring Heartburn/bloating/diarrhoea No food restrictions 100% compliance No alcohol restrictions Less drug interactions

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 5 – SR on workup/Pre-assessment Deferred 2 – raised TSH (above 10) 12 – low INR * If any of these issues caused a schedule delay or need to be discussed further, include details in next slide.

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 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

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