AFter all’s said and done

By

Kevin Kulendra

Abigail Hoyle

Thomas Bean

Iram Yasin

Sharon Wong

Chris Oscier

History Mr GC – 79yr old male (Retired Laundry Worker) [seen on 08/07/03]

PC – Cold & Painful R. Hand

HPC – 1/7 Hx of symptoms, awoken at 3am previous night- Dull ache in R.forearm exacerbated by gripping- Regular episodes (half hourly) at onset, less severe when seen- 1st episode of its type- no numbness / parasthesia

- no associated features, e.g. CP/SOB/palpitations/abdo. Pain/N&V

PMH – Hypertension for 1 year - BPH - Appendicectomy (‘47)

DH – Adalat 60mg od - Ramapril 2.5 mg od

FH – NAD / No Children

SH – Has lived with younger brother (74) in Wimbledon for past 5 years - Ex-smoker (20 pack years) - Non-drinker for past 20 years - lost wife 40 yrs ago - independent at home

SE – CVS – hypertension GUS - NADRS – Dry Cough MSS - NADGIT – Diarrhoea (3/7 ago) CNS - NAD

Examination CVS – Pulse 75 bpm / Irregularly Irregular

- BP 170/72- CR L – NAD / R – 5 sec- Pulses – Radial – R – absent / L - strong

- Brachial – R – strong / L – strong- Femoral – R – weak / L – strong- Popliteal – R- Weak / L – present- Dorsalis - R. Weak / L – present

- bilateral oedema of lower legs- no murmurs

RS – NAD Abdo – Soft / non-tender + appendicectomy scar in RIF Neuro - NAD

Impressions

Possible Diagnosis;

New Onset of Atrial Fibrillation, secondary to a cardiac event.

Established but undiagnosed Atrial Fibrillation with an embolus in the Right radial artery.

Myocardial Infarction presenting with a cold Right arm.

InvestigationsTemp 37.0°C, BP 167/90mmHg, P 82bpm, RR 24bpm,

Sats 96% on air, Glucose 5.7, GCS 15.Urinalysis - NADECG - AF, ?u waves (no indicators of an MI)Troponin T <0.01Doppler Pulses - normal on Left side, reduced on Right

side.

Management

Anticoagulation Heparin 5,000 i.u. S.C.Following reassessment post anticoagulation

Limb still cold (>12 hours after Heparin), ischaemic, without palpable pulses

Refer to the surgical team for Right Brachial EmbolectomyOperation was successful. Patient discharged on Warfarin

Summary

Patient presented with Atrial Fibrillation and Right Brachial Artery Occlusion.

Treated by the Medical team initially Failure to respond to anticoagulatin therapy, so

referred to surgeons for Brachial Embolectomy

Learning Issues - AF, Limb Ischaemia and Anti-Coagulation Therapy.

Acute Limb Ischaemia Affects upper and lower limb (amputation rate 16%,

mortality 22%)

Differential diagnosis Thrombosis in situ (40%) Emboli (38%) Graft/angioplasty occlusion (15%) Injury

Clinical Presentation

6 P’sPainPulselessPerishing with cold!PallorParaesthesia Paralysis

Sources of emboli Mural thrombus of right atrium + AF Previous MI Rarer sites

ValvesVentricular aneurysmAtrial myxomaAtheromatous plaque

Management Arteriography if diagnosis is uncertain iv heparin Embolectomy – Fogarty Balloon catheter Local thrombolysis – t-PA May need reconstruction Search embolic source

Echo USS

Epidemiology of AF AF= Chaotic irregular atrial rhythm~300-600 bpm Prevalence doubles with each decade Lip et al (1997) -Prevalence of AF 2.4%

HT (37%) - Common in Afro-Carribeans

IHD (29%) - Common in Indo Asians Slightly in men

Aetiology of AFCOMMONCOMMON

Heart Failure Hypertension Cardiac Ischaemia MI Mitral Valve Disease Pnuemonia Hyperthyroid Alcohol

RARERARE Cardiomyopathy Constrcitive pericarditis Sick sinus syndrome Bronchial Carcinoma Atrial Myxoma Endocarditis Haemochromatosis Sarcoidosis

Symptoms with atrial fibrillation

Often none Limited exercise tolerance (dyspnoea, fatigue) Angina Palpitations Presyncope and syncope Heart failure Stroke

Presentation Commonly presents as reduced exercise tolerance and heart failure.

Other presentations include dyspnoea, angina, palpitation and dizziness.

Symptoms may be more pronounced on exercise. Occasionally, emergency presentation;

presyncope, syncope, fatigue, dyspnoea, gross pulmonary oedema, angina, cerebral underperfusion, stroke.

Physical findings

Pulse irregular in rate, rhythm and volume. Variable intensity of the first heart sound. Absence of “a” waves in the JVP. With fast ventricular rates, an apex-radial pulse

deficit appears (weak contractions may be unable to transmit an arterial pulse wave through the peripheral artery).

Investigations History, examination and routine

Haematology, biochemistry and TFT’s. Diagnostic 12 lead ECG

Management of AF•Is it AF? - Confirm & Document Arrythmia

•Assess for cause & complications

•Acute - ensure haemodynamic stability

Acute AFAcute AF•Maybe Self-limiting

•Anticoagulate with IV Hep ± warfarin

•Treat compliactions

•Consider rate control or cardioversion

Chronic AFChronic AF

Paroxysmal AFParoxysmal AF

•Aim is to paroxysms and maintain sinus rhythm

•Consider anti-thrombotic therapy

•In resistant cases, consider non-pharmacological methods

Persistent AFPersistent AF

•Aim is to cardiovert to sinus rhythm

•Anticoagulate

•Consider anti-arrythmic therapy to maintain sinus rhythm post cardioversion

Permanent AFPermanent AF

• Aim is heart rate control and thromboprophylaxis

•Consider drug for rate control

•Consider warfarin or aspirin

•In resistant cases, consider non-pharmacological methods.

Sustained AFSustained AF

Heart failure

Sudden onset of fast AF may precipitate heart failure.

Especially if L.ventricular function is already compromised by co-existing heart disease.

Heart failure is associated with AF in approx 35% of cases.

Stroke Non-rheumatic AF increases the risk of stroke fivefold. AF is present in approx. 15% of patients presenting with

acute stroke. Risk of stroke in a patient with AF is about 5% a year.

The risk increases with age, BP, and evidence of other heart disease.

Increased risk of recurrent stroke and silent cerebral infarcts.

Patients with acute stroke and AF have higher mortality than those in sinus rhythm.

Thromboembolism

AF predisposes to the formation of intracardiac thrombus; this may result in stroke and thromboembolism.

Commonest site of thrombus is the left atrial appendage.

Right atrial thrombus with subsequent PE is a rare complication.

ANTICOAGULATION

INDICATIONS Previous thromboembolism Left atrial enlargement AF associated with:

valvular heart disease Left ventricular dysfunction Old age (>75) Hypertension

• Other Pt aspirin.• Young Pt (<60) with lone AF; no Rx

unless caused by alcoholic heart disease, thyrotoxicosis or sick sinus syndrome.

CONTRA-INDICATIONS Pregnancy Peptic ulcer disease Severe hypertension Bacterial endocarditis Non-thromboembolic stroke Haemostatic defect Caution with:

Hepatic and renal disease Recent surgery Breast feeding

MECHANISM OF ACTION WARFARIN ASPIRIN ACENOCOUMAROL (NICOUMALONE) PHENINDONE Side Effects:

Haemorrhage Hypersensitivity, rash, alopecia Jaundice, reduced haematocrit, hepatic

dysfunction Skin necrosis Pancreatitis Diarrhoea, nausea and vomiting

(Take at least 48-72 hrs to develop fully; if immediate anticoagulation necessary, concommitant heparin)

DOSE AND INTERACTIONS Induction 10mg daily for 2 days Subsequent maintenance depending on prothrombin ratio

Usually 3-9mg SAME TIME Target INR 2.5 Monitoring daily/alternate days early in Rx then at longer intervals (depending on

response) then up to every 12 weeks

AN INCREASED ANTICOAGULANT EFFECT DUE TO WARFARIN Decreased metabolism: TADs, cimetidine, phenothiazines, amiodarone Increased hepatic sensitivity: clofibrate, quinidine Decreased vit. K absorption: broad-spectrum antibiotics, cholestyramine Displacement from albumin: sulphonamides Platelet inhibition: aspirin Potentiation: alcohol xs (heart failure, liver/renal disease, thyrotoxicosis, fever)

A DECREASED ANTICOAGULANT EFFECT DUE TO WARFARIN Increased clearance by hepatic enzyme induction: rifampicin and barbiturates

Thank You