1. Atrial Fibrillation, AntiCoagulation
Mahesh Pauriah
Consultant Cardiologist & Cardiac Electro- physiologist

2. Case 1 74 year old lady Routine visit
Irregularly irregular pulse on examination
Mild SOB on moderate exertion
PMH: Hypertension
Meds: valsartan
Allergies Nil
Examination: HR 115 bpm , BP 135/76 mmHg
Heart sounds normal – chest clear

5. Bloods: 2 weeks ago
FBC: Hb 12.5 mg/dl, Normal Renal function
TFTs Normal
What would you do? – patient feels well

6. Rate control
Ant coagulate

7. Rate control : beta blocker – Bisoprolol 2
Rate control : beta blocker – Bisoprolol 2.5 mg BD , calcium channel blocker if asthma +/-Digoxin
Bisoprolol 2.5 mg BD , increase to 3.75 mg BD, then 5 mg DB- then change to once a day meds
Aim for a resting HR < 90 bpm

8. Anticoagulate : CHADSVasc Score
Warfarin
Xorelto , Dabigatran, Apixiban
? DC Cardioversion

9. Dental Issues
Endoscopy / Colonoscopy
Surgery
PCI- antiplatelets

10. 6 Months later – complains of increasing SOB,
Bilateral ankle oedema
Orthopnoea/ PND
ECG: Rate control AF
ECHO – severe LV Impairment.

11. Heart Failure Meds-
ACE inhibitor
Diuretics
Spironolactone.
Optimise meds

12. GI Bleeding

13. Atrial Fibrillation AF is very common More common in men than women.
AF rates in the population increases with increasing age.
lifetime risk of atrial fibrillation has been estimated to be 1 in 5 of the population

14. Background

15. Change with Time

16. Types of Atrial Fibrillation
(1) Paroxysmal AF is self-terminating, usually within 48 h
(2) Persistent AF: defined if AF episode either lasts longer than 7 days or requires termination by cardioversion, either with drugs or by direct current cardioversion (DCC)
(3) Long-standing persistent AF : if AF is present for ≥1 year

17. Natural History

18. Strategies to Treat AF
ANTICOAGULATION
RATE vs RHYTHM CONTROL

19. Risk of Stroke

21. Left Atrial Appendage Thrombus

22. Risk of Stroke Determine The Risk of Stroke
Risk of Bleeding with anticoagulation
CHADS Score or CHADSVASC Score

24. CHADSVASC and Risk of Stroke

26. Anticoagulation Warfarin – Keep INR between 2-3 NOAC Dabigatran
Rivoraxaban
Apixiban
Endoxaban

27. Tachy-Brady Syndrome

29. Symptomatic or poor heart rate control/ Intolerant to Meds

30. Anticoagulation Based on ChadsVasc Score Rate Vs Rhythm Control
For asymptomatic Patients rate control as good as rhythm control
Aim for resting HR < 90 bpm and < 110 bpm on exercise
For symptomatic patients- try to keep sinus rhythm
Trial of cardioversion for most patients

31. Rate Control Beta Blockers
Bisoprolol – start small and increase dose
Digoxin – may need to dose a level 6 nours post dose
Addition of Digoxin to Beta Blockers may reduce the dose of Beta Blockers required
Calcium channel Blockers- eg Diltiazem/ Verapamil- use with caution- Heart Failure

32. Case Study 2 35 year old man Marathon Runner
Episodes of Irregular Irregular Heart rhythm
Lasts for 4-6 hours
Bloods Normal
ECG Normal
Echo Normal
Several Holter monitor Normal

33. Modern Technology

34. ALIVECOR

37. Example of Transmission

38. Diagnosis
Paroxysmal Atrial Fibrillation
Treatment
Medical
Ablation

39. Medical Management of AF
Reassurance- this is not not going to lead to death/heart attack
Refrain from Binge Drinking
Relax
“Ride it out”
Seek help if unwell
Pill in the pocket
Flecainide & Beta Blockers

40. Flecainide Excellent Drug However, can lead to arrhythmia
Make sure ECG Normal
ECHO Normal
No Evidence of Coronary Artery Disease
Danger with Atrial Flutter and Flecainide alone

41. Atrial Fibrillation Ablation
For Troublesome symptomatic AF

42. Atrial Fibrillation Ablation

44. Success Rates Success rates variable Works well with Paroxysmal AF
Redo rates
Less well with Persistent
Poor with Longstanding Persistent AF

45. Complications Stroke- 1:200
Use Heparin intra-procedural
Groin Haematoma – requiring Intervention 1:200
Tamponade 1:200
Emergency Operation or Death 1: 1000

46. Stroke in Young Man 40 year old man PMH: Nil Meds : Nil Allergies: Nil
Admitted with Stroke
Good Recovery

47. Investigations Bloods Normal , Including vasculitis Screen
MRI Confirms CVA
ECG
ECHO
Bubble Echo
Holter Monitor – Normal

48. Bubble Echo

49. What Next

51. How to Implant

52. Automatic Transmission

53. Unrelated Case 65 year old man with sudden LOC a few weeks ago
Seen in AE – discharged
Seen at MPH – ECG/Echo /ETT Normal
Holter Normal
Loop Recorder

56. Plan:
Bloods/ TFTs
Anticoagulation

57. Anticoagulate
Holter monitor – to ascertain rate control
DC Cardioversion -3 weeks before and 4 weeks afterwards

59. Case 3 84 year old Dizzy spells Bisoprolol 10 mg OD Diltiazem
PMH: Hypertension
Meds: As above

61. Admit
Stop all rate limiting drugs
Anticoagulation
Monitor – BP stable
No temporary wire
HR settled mild tachycardia after 4 days.
Started on Bisoprolol 1.25 mg OD- HOME no pacemaker . Well 9 months later

62. Case 4 76 year old man Previously well January – fell
Subdural Haematoma
2 weeks in CUH
Treated Conservatively
Asprin Stopped

63. PMHX : Hypertension
Discharged 2 weeks later
Change in Personality
Dizzy,

64. Recurrent admissions to Hospital since then – repeat CT bleed getting better
Noted to have an irregular pulse
Holter : Episodes of atrial Flutter

65. ECG

66. Discussed with Neurosurgery
Admitted to Hospital
Rate controlled
Bisoprolol / Digoxin –
Discussed with Neurosurgery
Risk of bleeding high
Repeat Scan in 2 weeks
CHADSVasc Score 3:

68. Atrial flutter Ablation

69. Atrial Flutter

70. Repeat CT Scan today – SDH almost resolved
Can go on a NOAC

71. Case 5 78 year old gentleman Previous Bowel cancer
Treated with surgery and radiation – 5 years ago
6 months history of SOB and palpitations

72. Examination : Gross heart failure
Treated with diuretics
Rate control : Digoxin and beta blockers
Ramipril 5 mg BD
Spironolactone
Warfarin
Echo : EF of about 20% [ normal > 50%]

74. Much better rate control Discharged Home
Heart rate settled
Much better rate control
Discharged Home
Medications on Discharge
Warfarin
Bisoprolol 10 mg
Digoxin 125 mcg
Ramipril 2.5 mg OD
Spironolactone 25 mg OD

75. Medications Optimised
Warfarin
Ramipril 5 mg BD
Bisoprolol 10 mg
Digoxin

76. 3 months later NYHA 3 On Optimal Meds
Anti coagulated- Recurrent PR Bleeds
LBBB and rate controlled AF

77. Treatment options for patients with chronic symptomatic systolic heart failure (NYHA functional class II–IV).
Treatment options for patients with chronic symptomatic systolic heart failure (NYHA functional class II–IV).
Authors/Task Force Members et al. Eur Heart J 2012;33:
© The European Society of Cardiology All rights reserved. For permissions please

79. Biventricular Pacemaker

80. Amiodarone – well loaded Cardioverted EF almost normal NYHA 1
Almost back to normal .
Recurrent bleeds requiring transfusion

81. Changed warfarin to Apixiban 5 mg BD
Still PR Bleed- requiring transfusion

83. Lower dose of NOAC- bleed SR for 6 months- stop all anticoagulants
Declined watchman
Lower dose of NOAC- bleed
SR for 6 months- stop all anticoagulants
Atrial Fibrillation alarm

84. Cardiac Electrophysiology, Arrhythmia & Heart Failure

85. Drugs for Heart Failure

86. Heart Failure

87. THANK YOU