NON-RHEUMATIC ATRIAL FIBRILLATION etiology and investigation Aetiology Atrial fibrillation (AF) is commonly associated with hypertension, ischaemic heart disease, mitral valve disease, cardiomyopathy (including alcohol), chest infection and hyperthyroidism. Investigations ECG, renal function & electrolytes, thyroid function tests. Consider: Chest X-ray, echocardiogram. Ventricular rate control Digoxin Effective for rate control but not in restoring sinus rhythm. Avoid in paroxysmal atrial fibrillation. Beta-blocker, If the ventricular rate remains uncontrolled despite adequate Verapami digoxin concentration consider adding a beta-blocker or Amiodarone. diltiazem, or, in the presence of poor LV function, using amiodarone instead. Anti-thrombotic Therapy Warfarin Substantial reductions in the risk of stroke can be achieved or with warfarin or, to a lesser extent, aspirin. The choice of Aspirin agent for each individual patient is governed by their absolute risk of stroke vs the risk of bleeding complications. Stroke risk is increased with significant structual heart disease. Patients aged > 65 years with chronic AF (and those of all ages with rheumatic AF) without clear contraindications should be considered for long-term anticoagulation (target INR 2.0-3.0) unless compliance and/or complications are thought likely to be a problem. For these patients and those < 65 years, consider using aspirin 75-300mg daily. Cardioversion and maintenance of sinus rhythm (see Figures 5a & 5b) Aims of cardioversion To relieve symptoms and to avoid long-term anticoagulation. Patient selection Most likely to succeed in younger patients (<75 years) with recent onset AF (< 1 year), particularly if there is no major structural heart disease. Medical therapy Warfarin Anticoagulate with warfarin for 1 month before elective electrical cardioversion (target INR 2.5 - 3.5) and continue for 1 month after reversion to sinus rhythm. Antiarrhythmic Consider prophylactic anti-arrhythmic treatment drugs (eg amiodarone) before elective DC cardioversion and continue following return to sinus rhythm. Indications for referral Diagnosis/aetiology Uncertainty about diagnosis or treatment of the underlying condition or threshold for anticoagulation. Cardioversion Consider referral in younger patients (<75 years) and those with AF of recent onset (< 1 year). Persistent symptoms Unpleasant or disabling symptoms that are not relieved by treatment; failure to control ventricular rate.Stroke reduction in atrial fibrillation For g ‘with atrial fibrilation. Eur Heart J 2001; 22: 1852-1923, ldelines on management of atrial fibrillation and review of literature see ACUAHAVESC guidelines for the management of patients Evidence Observational studies Intervention Reducing risk of stroke Summary of benefits/risks Chronic AF is uncommon under 50 years, but reaches 10% by 80 years. Approximately 15% of all strokes may be attributable to atrial fibrillation. Untreated, overall incidence of stroke in chronic AF is 5% per year (2% per year in paroxysmal AF)but risk rises rapidly with age: < 65 years stroke risk is 1% per year; at 65 to 80 years risk is 396 per year, and >80 years rsk is 8% per year. Key references Camron A, Swart My Krona RA st Si Frewlence and significance of atl Aion n coronary hear dase. {Cissreghty. am! Cardiol 156 sire Wolf PA, Abbot RD, Kanne WA. Atal baleen: major conbuton soke nthe elder. Avch intern Med ‘sera isst Randomised controlled trials and systematic ‘overview of randomised tials. Anti-thrombotic Therapy ‘Warfarin (INR 2 to 3) The collaborative ‘and indirect ‘control with ‘those of warfarin v control) suggest that warfarin is more effective at preventing stroke than aspirin, Warfarin is therefore the treatment of ch for most patients with paroxysmal fibrilla However, if there uncertainty about how well anticoagulation can be monitored and controlled, medium- dose aspirin (75 to asafe Individual trials and the systematic overview report relative risk reductions of stroke of 60 to 80% i.e. 3 to 4% reduction in absolute risk or fone stroke prevented each year for every 25 to 35 patients treated, but... a) adverse effects under trial Conditions included a small rise in severe haemorrhage (intracranial bleed, bleed requiring admission to hospital or transfusion of 2 units of blood) from 19% to 1.3% year, and... b) the trials were very selective criteria, entry Consider likely risk-benefit ratio, the ability to monitor INRs and patient ‘compliance before choosing an agent. If ‘outside trials than under conditions then the benefits may be less and the adverse effects greater than suggested by the trial data. The following table may guide treatment: ‘AGE RISKFACTORS ADVICE | rate contl*/ maintenance) Succeeds, | (OP review, echocardiography |¢——