1. Atrial Fibrillation: An old age problem PCCS Village Hotel 18 th May 2011

2. The Challenges for the GP The ECG when diagnosing AF The question of rate vs rhythm To warfarinise or not! Do I need to do anything else? :When to refer?

3. Atrial Fibrillation The 3 Ps Paroxysmal: Recurring sudden episodes of symptoms Persistent : Lasting longer than 7 days, unlikely to revert back without treatment Permanent: Present long term and has not been able to be converted back to normal

4. Causes of Atrial Fibrillation Ischaemic heart disease Valvular problems Cardiomyopathy Thyrotoxicosis PE Alcohol/caffeine intake 1 in 9 cases no cause = lone AF

5. Presentation at the Surgery

6. Does this patient have AF ?

7. What about this one?

8. Diagnosis Perform an ECG in all suspected patients Use 24 hour ECG monitoring or event recorders for paroxysmal AF Bloods including TFT, consider CXR

10. Rate vs rhythm Try rhythm-control first for patients with persistent AF: who are symptomatic who are younger presenting for the first time with lone AF secondary to a treated or corrected precipitant with congestive heart failure.

11. Drugs for rhythm control Rhythm control for persistant AF starts with cardioversion Otherwise first line is standard beta blocker With no structural heart disease second line is Sotalol or a class 1c Third line is Amiodarone (second line in structural heart disease)

12. Rate Vs Rhythm Try rate-control first for patients with persistent AF: over 65 with coronary artery disease with contraindications to antiarrhythmic drugs unsuitable for cardioversion.

14. Drugs for rate control (not paroxysmal) Target resting heart rate less than 90 bpm (110 in recent onset) Target exercise heart rate 110 in the inactive and 200 minus age in the active 1 st line, beta blocker or calcium channel blocker 2 nd line, add digoxin If all else fails refer (or consider amiodarone)

15. Should I be doing an echocardiogram? younger patients if you are considering cardioversion, if you suspect structural or functional disease with clinical evidence of LV dysfunction or valve disease

17. Warfarinistation A 75 year old patient presents with AF on a 24hr monitor and an echocardiogram shows LV dysfunction. What else do you want to know?

18. PMHx COPD, Ulcerative Colitis, Osteoarthritis, Hypercholestraemia DHx Ramipril 2.5mg BD Furosemide 40mg, Simvastatin 40mg Asacol 400mg SHx Lives with wife no alcholol

19. Do you give him warfarin? How would you decide?

20. NICE Guidance

21. CHADS2 Scoring

22. Risk of stroke CHADS2 ScoreStroke Risk95 %CI 01.91.2-3.0 12.82.0-3.8 24.03.1-5.1 35.94.6-7.3 48.56.3-11.1 512.58.2-17.5 618.210.5-27.4

23. Patient GR Aged 78 Diagnosed with AF on his ECG Echo Mildly impaired LV function DHx Ramipril 5mg bd bisoprolol 5mg furosemide 40mg Social history Drinks sixteen cans a day of lager Recovering drug addict living in hostel Do you warfarinise him?

24. To refer or not to refer. Consider referral for further specialist intervention for patients: – in whom pharmacological therapy has failed – with lone AF – with ECG evidence of any underlying electrophysiological disorder such as Wolff– Parkinson–White syndrome.

25. Key points Anticoagulation is important First line treatment Rate Control with beta blocker/ca-antagonist NOT Digoxin Consider echo Consider referral