Making Best Practice, Every Day Practice
Atrial fibrillation (AF) is the commonest cardiac arrhythmia seen in primary care and, if left untreated, is a significant risk factor for stroke. New guidelines from the National Institute for Health and Care Excellence (NICE) include some practice-changing recommendations on diagnosing AF, the role of aspirin and the novel oral anticoagulants (NOACs), and shared decision-making to ensure patient-centred care.
Warfarin is highly effective in preventing strokes in people with atrial fibrillation (AF), but has its limitations. Only half of patients who could benefit actually receive warfarin, resulting in an estimated 7000 avoidable strokes each year.
Stroke is devastating – for the person affected, their family and the NHS. Figures in the recent NICE guideline on stroke show that around 110,000 people have a first or recurrent stroke each year in England, and a further 20,000 have a transient ischaemic attack (TIA).
Antiplatelet (usually aspirin) and anticoagulant (usually warfarin) treatments are available to reduce the risk of stroke in patients with atrial fibrillation (AF) but both have potentially harmful adverse effects and warfarin can be time-consuming and expensive to monitor. Guidance exists for choosing between treatments but is often insufficiently detailed to support an informed choice about the risk and benefits. Prescribers and patients are often left with a choice between aspirin or warfarin, and aspirin – which is perceived to be safer and easy to use – is often chosen. This article explores the evidence for aspirin and warfarin in preventing stroke in patients with AF, and describes how we should change the way that decisions about treatment are made.
Irrespective of whether the atrial fibrillation is constant or occurs in paroxysms, that is, it is intermittent, the decision to administer antiplatelet drugs or anticoagulants should depend on the patient’s cumulative risk factors. These risk factors include age and previous medical history.
Atrial fibrillation (AF) is becoming an epidemic, affecting 1% to 2% of the population in the developed world. Looking to the future, the prevalence of AF will grow dramatically in the coming decades as the elderly population increases. The growing numbers underline the need to improve the detection of patients with AF and measures for reducing their risk of stroke.
The prevalence of atrial fibrillation (AF) is increasing with the ageing population. It is well worth detecting and treating as it carries a significant risk of debilitating disease, including stroke and heart failure. This article explains some of the health risks and describes simple actions that can play an important part in both the prevention and management of AF and its consequences.
Each year there are 150,000 strokes in the UK. Nearly one in five (18%) of the people presenting with a stroke are in atrial fibrillation (AF) at the time of presentation, and one in six strokes are directly attributable to AF. The risk of stroke in AF is reduced by two-thirds with oral anticoagulation, while antiplatelet therapy reduces stroke by one-fifth. The reduction with antiplatelet therapy is broadly consistent with the stroke reduction seen with this therapy in patients with vascular disease or risk factors, and, given that AF largely coexists with vascular disease, the effect of antiplatelet therapy would probably reflect this. The risk of stroke is similar with paroxysmal or permanent AF, in the presence of associated risk factors.
Hyperkalaemia is a common electrolyte disorder which, when severe, can cause lifethreatening cardiac arrhythmias and paralysis of the respiratory muscles. It is therefore crucial for clinicians to have a clear understanding of its management. Hyperkalaemia is usually caused by a combination of factors, but renal impairment and drugs are often implicated. The rising prevalence of chronic kidney disease and increasing use of medications that interact with the renin-angiotensin-aldosterone system have resulted in a sharp rise in the prevalence of hyperkalaemia.
Catheter and surgical ablation of cardiac arrhythmias have evolved rapidly over the last 30 years. Catheter ablation of ‘simple’ atrial arrhythmias such as supraventricular tachycardias and typical atrial flutter is very successful and low-risk. Catheter ablation of atrial fibrillation (AF) is now also successful in restoring sinus rhythm for the majority of patients. The place of invasive treatment for ventricular arrhythmias in various contexts is also evolving.
Following implementation of the Department of Health’s Chapter 8 of the National Service Framework in 2005, there has been expansion of arrhythmia services in the UK. In 2010, the capacity of hospitals to treat these arrhythmias is growing rapidly, and perhaps the main barrier to patient access is the limited awareness among would-be referring physicians of which patients should be referred for such treatments. This review article outlines the ways in which arrhythmias can be treated by catheter and surgical ablation, and provides success and complication rates to help the reader determine when, and for whom, these treatments might be appropriate.
Supraventricular tachycardia (SVT) often begins in childhood or early adulthood. In this review, a patient describes her experience of coping with episodes of SVT and the experience of undergoing cardiac ablation and subsequently having a pacemaker fitted.
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