Atrial fibrillation

Atrial fibrillation

Sep 16, 2014 0
cardiology,General medicine,onthepods

James talks to Professor David Celermajer on managing atrial fibrillation on the wards.

Editor:  James Edwards

Interviewee:  David Celemajer

About David Celemajer

Professor David Celermajer is the Scandrett Professor of Cardiology at The University of Sydney, Director of Echocardiography in the Cardiology Department as well as Director of Adult Congenital Heart Services, at Royal Prince Alfred Hospital. He has been Group Leader of the Clinical Research Group of the Heart Research Institute since 1994, and in 2003 was appointed as Clinical Director of the Heart Research Institute. He gained his Fellowship of the Australian Academy of Science in 2006 and graduated with First Class Honours, University Medal for 1st in his graduating class, from Faculty of Medicine, University of Sydney in 1983.

In 1983 he was also awarded the Rhodes Scholarship for New South Wales and in 1984 become the World Debating and Public Speaking Champion. In 1998, he was awarded the RT Hall Prize for most outstanding contribution by a senior cardiac investigator, by the Cardiac Society of Australia and New Zealand. David was also awarded the Eric Susman Medal for Research, for most outstanding contribution to any branch of Internal Medicine, by the Royal Australasian College of Physicians in 1998.

In 2002 he received the Commonwealth Health Minister’s Award for Health and Medical Research for his outstanding lifetime contribution. David was also the recipient of the Simon Dack Award for excellence in cardiology from the American College of Cardiology in 2010, and the NSW Health Minister’s Award for Lifetime Achievement in Cardiovascular Research in 2012.

Atrial Fibrillation

With Professor David Celermajer, Cardiologist at Royal Prince Alfred Hospital, New South Wales, Australia

  • Ask what their obs are – Do they look cold and clammy, are they alert, what are their sats and BP?
  • What is the context – why are they in hospital?
  • Could the nurse please do an ECG while you make your way to the ward?
  • General impression – how sick do they look from the end of the bed?
  • Should you be escalating this to an ICU review or Emergency call?
  • Check pulse
  • Is there an acute precipitant?
  • Is there a clear history of onset of symptoms?
  • This is important as AF less than 48 hours decreases risk of having atrial thrombus and may not require a TOE prior to cardioversion
  • If unsure of onset time, assume they have been in AF > 48 hours
  • Big 4 precipitants in the hospital setting: post operative state, post infarct state, sepsis and anaemia
  • Is there a history of cardiac disease?
  • What medications are they on
  • It is important to know if they have underlying heart disease because it will influence to the choice of medications that may be given.
  • Need to assess perfusion and focus on vital signs
  • Look for signs of heart failure and pulmonary oedema. Is the JVP raised? Listen to the chest
  • If they are in heart failure they may need resp support in a critical care environment
  • Look for precipitant – Sepsis, Anaemia, New Infarct, hypovolaemia, electrolyte abnormalities
  • ECG
    • Look for rhythm, look for signs of ischaemia; acute and old signs including ST changes and old q waves
    • What is the rate, what is the rhythm; make sure it is narrow complex and not broad complex. If broad or not sure – Get help early
  • EUC and CMP: Important to check K and Mg in particular and replace if low
  • Check TFT’s if they haven’t been check recently
  • FBC to look for anaemia
  • Investigations to look for sepsis in context of at risk patient
  • Consider organising an ECHO especially if unsure if there is underlying cardiac disease
  • Should we do a troponin? Short answer is YES but….
    • AF decreases diastolic flow because you lose the atrial kick and Diastole shortens disproportionately with tachycardia
    • This means in there may be demand ischaemia in patients with underlying cardiac disease, particularly the elderly. A modestly raised troponin in this context may not necessarily indicate acute coronary vessel obstruction and may be an indicator of global ischaemia
    • If the troponin is very high and has a delta change it may be an indicator that acute ischaemia WAS the PRECIPITANT
  • Do a DRS ABC assessment. Ask for help early if patient looks unwell or has signs of instability
  • Unstable patients should be considered for cardioversion early
  • 2 main groups of people with AF:
    • People with a structurally normal heart – electrical abnormality at back of atrium or acute precipitant
      1. Respond well to short acting medications
      2. Sometimes require long-term antiarrhythmic therapy. 3 on the wards on the pods Atrial Fibrillation on the wards
      3. Don’t usually require long-term anticoagulation
  • People with underlying structural heart disease where the atrium is chronically diseased. Most common causes of this are previous myocardial infarction and Cardiomyopathies
  1. Acute management with BBlocker should be used very cautiously in this group
  2. More likely to require long term antiarrhythmics
  3. More likely to require long-term anticoagulation
  • Should my patient be anticoagulated? Short answer is YES but…..
    • Check for contraindications before commencing anticoagulation
    • There is a risk of Atrial thrombus for 2 weeks following cardioversion even if it was spontaneous or chemical cardioversion. Anticoagulation tends to be given to most people for 2 weeks following an episode of AF
    • Can use Clexane, or Warfarin or one of the new ones (rivaroxiban, Dabigatran)

 

  • Should we be aiming for rate or rhythm control?
    • Depends on patient. Many of the rate controlling medications may also result in cardioversion and vice versa
    • 70% of patients will revert to sinus in 12 hours with just NSaline
    • 70% of patients given digoxin will revert to sinus
    • 90% of patients givenSotalol will revert to sinus
    • 90% of patients given amiodarone will revert to sinus
    • BBlockers, especially IV BBlockers, can be dangerous in patients with poor LV function in the acute setting
    • Amiodarone can be useful in the acute setting in patients with poor LV function but has a high side effect profile
    • Oral BBlockers tend not to be as dangerous and can be good for rate control
    • Digoxin can be a good option in a patient with poor LV function
  • Ask for help early if unstable: “Unstable” includes patients with signs of pulmonary oedema, the cold and clammy patient and the hypotensive patient
  • Big 4 precipitants in the hospital setting: post operative state, post infarct state, sepsis and anaemia
  • Try to ascertain if they have an underlying heart condition
    • If unsure which group they belong in, try to get an ECHO performed before giving medications for AF
  • If unsure of onset time, assume they have been in AF > 48 hours
  • AF more than 48 hours or unsure of onset, needs anticoagulation prior to cardioversion
  • All patients should be anticoagulated for at least 2 weeks post cardioversion

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Tags: #anticoagulation,#arrhythmias,#arrythmias,#Atrial Fibrillation,#cardiology,#conduction,#ECG,#echocardiogram,#electrolytes,#fibrillation,#thyroid

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