af clinical approach - workshop
TRANSCRIPT
ATRIAL FIBRILLATION
CLINICAL APPROACH
AF WORKSHOP 2014
PRINCIPLES OF AF MANAGEMENT
(1) Rate control.
(2) Prevention of thromboembolism.
(3) Optimal management of etiology
concomitant disease & complications.
(4) Symptom relief.
(5) Correction of rhythm disturbance.
CLINICAL APPROACH
CLINICAL HISTORY
EXAMINATION
RELEVANT INVESTIGATION
DEFINE TYPE OF AF
STRATIFY FOR STROKE PREVENTION
STRATIFY BLEEDING RISK
CONTROL RATE
TREAT CAUSES/COMPLICATIONS
IDENTIFY & CLOSE MONITOR HIGH RISK PT
CLINICAL HISTORY
Acutely unwell : unstable
Symptomatic :
- Dyspnoea
- Palpitation
- Lethargy
- Dizziness
- Syncope
- Chest pain/discomfort
Associated condition or
complications :
- Heart failure,
- ACS
- Thyrotoxicosis,
- Stroke
- SA node dysfunction
Opportunistic :
- Asymptomatic
- Incidental
- Non specific symptoms
STRATIFY SYMPTOMS
PHYSICAL EXAMINATION
BP, HR : manual,pulse check
CVS/RESP/CNS/THYROID etc
RELEVANT INVESTIGATIONS
12 lead ECG : confirm diagnosis & rate
TRANSTHORACIC ECHOCARDIOGRAPHY
- valvular vs non valvular vs structural lesion
- LV function, LA size
- intramural clot
- LVH etc
RFT/LFT/FBS/RBS/COAGULATION/TFT /LIPIDS
etc
CXR
DEFINE TYPE OF AF
VALVULAR AF :
- valvular
- rheumatic heart
disease
- prosthetic valves
NON VALVULAR AF
STRATIFY FOR STROKE PREVENTION
VALVULAR AF
- ANTICOAGULANT
NON VALVULAR AF
DO CHADS2 or CHA2DS2VASc score
- ANTICOAGULANT
or
- ANTIPLATELET
or
- NONE
CHADS2 SCORE ANTITHROMBOTIC THERAPY
0 → ASPIRIN OR none
1 → ORAL ANTICOAGULANT or aspirin
≥ 2 → ORAL ANTICOAGULANT
* Heart failure or LVEF ≤ 40%
*
CHA2DS2-VASc SCORE
CHA2DS2-VASc score antithrombotic therapy
0 → none or aspirin
1 → oral anticoagulant or aspirin
≥ 2 → oral anticoagulant
Vascular disease : MI, PVD, Aortic plaque * LVEF ≤ 40%
*
WHICH SCORING SYSTEM ?????
CHADSVASc – provides a more accurate estimation of risk
THE BEST APPROACH……
DO CHA2DS2-VASc SCORE
FROM THE START
DO CHADS2 SCORE FIRST
IF SCORE : 0 OR 1
DO CHA2DS2-VASc SCORE
STRATIFY BLEEDING RISK- HAS-BLED SCORE
≥ 3points: HIGH RISK
CONTROL RATE
PRIORITY FIRST IS RATE CONTROL
PERSISTENT & PERMANENT AF- RATE CONTROL
PAROXYSMAL AF - NO RX
- RATE CONTROL
- RHYTHM CONTROL
CHOOSE BEST DRUG
SET VENTRICULAR RESPONSE RATE
TREAT
REVERSIBLE CAUSES
UNDERLYING PERPETUATING CONDITION
COMPLICATIONS
ASSOCIATED CONDITIONS
IDENTIFY & CLOSE MONITOR HIGH RISK PT
Clinical Hx, Examination
↓
ECG, Echo, CXR, bloods – TFT, RFT,LFT,LIPIDS, FBS etc
↓
Define- type of AF
↓
Stratify : - risk of stroke ( valvular or CHADS2 or CHA2DS2VASc score )
- risk of bleeding (HAS-BLED score )
↓
RX- Rate control first & anticoagulant as indicated
↓
Treat causes, ppt , complications , asstd conditions
↓
Identify & close monitor high risk pt
APPROACH IN STABLE , ASYMPTOMATIC / MINIMAL SYMPTOMS AF
Clinical Hx, Examination
↓
ECG, Echo, CXR, bloods – TFT, RFT,LFT,LIPIDS, FBS etc
↓
Define- type of AF
↓ RX- Rate control first & complications
↓
Stratify : - risk of stroke (valvular or CHADS2 or CHA2DS2VASc score )
- risk of bleeding (HAS-BLED score )
↓
RX- anticoagulant as indicated
↓
Treat causes, ppt , asstd conditions
↓
Identify & close monitor high risk pt
APPROACH IN STABLE , SYMPTOMATIC AF
Quick : Clinical Hx, Examination
↓
RX- Cardioversion & IV heparin / LMWH
↓
ECG, Echo, CXR, bloods – TFT, RFT,LFT,LIPIDS, FBS etc
↓
Define- type of AF
↓
Stratify : - risk of stroke (valvular or CHADS2 or CHA2DS2VASc score )
- risk of bleeding (HAS-BLED score )
↓
RX- anticoagulant ,rate or rhythm control as indicated
↓
Treat causes, ppt , complications , asstd conditions
↓
Identify & close monitor high risk pt
APPROACH IN UNSTABLE AF