Story 2- Atrial Fibrillaton - a hidden disease

Arrhythmia Alliance E-Bulletin

“Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmia”

Common, treatable, but often unrecognised-atrial fibrillation, a hidden disease

December 2006

Registered Charity No. 1107496

EXTRACT FROM THE ROYAL COLLEGE OF PHYSICIANS WEBSITE

Atrial fibrillation (AF for short) is a condition that affects the heart causing an irregular pulse, and is the commonest sustained abnormality of the heart's normal regular rhythm. Although a common condition affecting over one in ten people over 75, it is not always recognised immediately as the symptoms are similar to those of other medical conditions.

Atrial fibrillation is important to diagnose early as it is a major risk factor for stroke - people with AF have a one in twenty chance of having a stroke. New guidelines commissioned by NICE from the National Collaborating Centre for Chronic Conditions (NCC-CC), based at the Royal College of Physicians, aim to help GPs and other healthcare professionals recognise and treat AF. The guidelines are being launched at an international one-day conference hosted by the Royal College of Physicians on Tuesday 10 October to emphasize the importance of diagnosing and treating this condition.

The prevalence of AF roughly doubles with each advancing decade of age from 0.5% at age 50-59 to almost 9% at age 80-89. In addition to the risk of stroke, it is an important condition because it can cause a variety of symptoms such as palpitations, chest pain, shortness of breath, dizziness and fainting and severe problems which can be life-threatening.

The aim of treatment of AF is to control the heart rate and rhythm. There are different types of AF and the guideline recommends slightly different treatment options for each. Persistent AF lasts for longer than 7 days and typically requires cardioversion - either pharmacological or electrical - to help the heart return to its normal rhythm. Permanent AF is more longstanding (usually longer than a year) and which cannot be successfully treated with cardioversion. Paroxysmal AF comes and goes, and usually stops within 48 hours without treatment. Acute-onset AF is an episode of AF that has started suddenly or has worsened existing symptoms. This type of AF can occur in people with persistent or paroxysmal AF who may already being treated for their condition. Post-operative AF may occur after surgery (especially cardiothoracic surgery). The guideline's key recommendations are:

Identification and diagnosis

· An electrocardiogram (ECG) should be performed in all patients, whether symptomatic or not, in whom atrial fibrillation (AF) is suspected because an irregular pulse has been detected.

Treatment for persistent AF (AF lasting longer than 7 days)

· As some patients with persistent AF will satisfy criteria for either an initial rate-control or rhythm-control strategy (for example, age over 65 but also symptomatic):

· The indications for each option should not be regarded as mutually exclusive and the potential advantages and disadvantages of each strategy should be explained to patients before agreeing which to adopt

· Any comorbidities that might indicate one approach rather than the other should be taken into account

· Irrespective of whether a rate-control or rhythm-control strategy is adopted in patients with persistent AF, appropriate antithrombotic therapy should be used.

Treatment for permanent AF (AF which is more longstanding [usually longer that a year] and which cannot be successfully treated with cardioversion)

· In patients with permanent AF, who need treatment for rate-control:

o beta-blockers or rate-limiting calcium antagonists should be the preferred initial monotherapy in all patients

o digoxin should only be considered as monotherapy in predominantly sedentary patients.

Antithrombotic therapy

· In patients with newly diagnosed AF for whom antithrombotic therapy is indicated such treatment should be initiated with minimal delay after the appropriate management of comorbidities.

· The stroke risk stratification algorithm [provided in the guideline] should be used in patients with AF to assess their risk of stroke and thromboembolism, and appropriate thromboprophylaxis given.

Dr Michael Rudolf, Chair of the Guideline Development Group and Consultant Physician, Ealing Hospital, said: "As a general physician working in a busy district general hospital, I see far too many patients with undiagnosed atrial fibrillation admitted with strokes, which could almost certainly have been prevented if only the cardiac arrythmia had been spotted and treated earlier. This new guideline provides a golden opportunity to review how we can improve the early diagnosis and correct management of this common disorder."

Professor Gregory YH Lip, Professor of Cardiovascular Medicine at City Hospital, Birmingham, and Clinical Adviser to the Guideline Development Group, said: "AF is very common and its management is often suboptimal and neglected. With the increasing age of the general population, AF is becoming a major public health problem, especially as it predisposes to strokes and heart failure. The appropriate use of antithrombotic therapy in AF will substantially reduce the stroke risk and the management options detailed in this important, evidence-based clinical guideline would help our management of this common condition."

§ Atrial Fibrillation - National clinical guidelines for management in primary and secondary care

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