The future of atrial fibrillation management: integrated care and stratified therapy Flashcards
What are the five domains of AF management?
- Acute management
- Treatment of underlying and concomitant cardiovascular conditions.
- Stroke prevention therapy
- Rate control
- Rhythmn control
Common symptoms in people with atrial fibrillation are
Fatigue SoB Palpitations Anxiety Depressed mood
Silent AF patients are at risk of
Normal complications:
Stroke, HF or sudden death.
Need to identify people with it
How can we identify those with AF?
ECG screening, particularly in at risk populations and those who have had a stroke,
How are patients with atrial fibrillation that has been identified by ECG screening managed?
Most will also have stroke risk factors that make them eligible for oral anticoagulation.
Patients with silent AF should be investigated for concomitant CV conditions that require therapy.
Rhythm control is not required in patients with silent AF unless they develop AF symptoms.
The presence of AF in a patient indicates what?
The presence of atrial fibrillation strongly indicates that other cardiovascular conditions might exist. To identify such conditions, a careful cardiovascular examination and an echocardiogram should be done in all patients with atrial fibrillation at the time of diagnosis. In young patients with atrial fibrillation, the ECG should be examined for signs of inherited arrhyhthmogenic diseases. Comprehensive diagnosis and treatment of cardiovascular risk factors and concomitant diseases2, 53 should be an integral component of atrial fibrillation management.
How is hypertension managed in AF and why?
High BP = number one risk factor for stroke, people with AF are 5x more likely to have a stroke.
ACEi and ARB are slightly more effective at preventing AF than other agents.
How is heart failure in AF managed?
B-blockers can be safely used, but they do not have a demonstrable prognostic effect in patients with atrial fibrillation and heart failure.
” In the acute setting, distinguishing symptoms of heart failure from atrial fibrillation symptoms is often difficult, especially in patients with preserved or moderately impaired ejection fraction. A careful reconstruction of symptoms and disease signs over time often helps, and occasionally restoration of sinus rhythm is useful to distinguish atrial fibrillation-associated symptoms from heart failure.”
Patients with AF and mechanical heart valves require what type of oral anticoagulation?
Vitamin K antagonists
How does obesity contribute to AF?
Possible via:
Activation of adipocytes in the atria or by fatty infiltration of atrial myocardium.
How is CAD managed with AF?
CAD can be managed with an anticoagulant without further antiplatelet therapy in patients who are stable.
How is stenting or ACS (in CAD) and AF managed?
The increased bleeding risk following stenting/ACS needs to be balanced against the need to prevent recurrent thromboembolic events.
Usually, this balance can be achieved by short-term combination therapy for 1-12 months: consisting of an anticoagulant, clopidogrel and aspirin.
What form does oral anticoagulant therapy for stroke prevention in AF take?
Oral anticoagulant therapy with vitamin K antagonists or NOACs prevents most ischaemic strokes in patients with AF at risk for stroke.
Antiplatelet therapy does not prevent strokes in patients with AF.
Patients with AF with two or more clinical stroke risk factors benefit from oral anticoagulation.
What NOACS can be used in patient with AF for stroke prevention?
Apixiban
Dabigatran
Edoxaban
Rivaroxaban
Rate control in AF is achieved via
Pharmacological slowing of the atrioventricular node using B-blockers, digoxin or verapamil/diltiazem (RL-CCB).
Even with adequate rate control therapy, many patients with atrial fibrillation remain symptomatic, thus requiring adaptation of rate control therapy in addition to rate control.
