The debate: Should all AF patients see an EP consultant?

Transcription

1 The debate: Should all AF patients see an EP consultant? Pre-debate show of hands in favour of the motion The argument for the motion: Dr Nick Kelland The argument against the motion: Dr Andy McCoye Discussion Post-debate show of hands in favour of the motion Post-debate show of hands of anyone who has altered their referral threshold in view of the debate

2 All patients with AF should be referred to a CRM specialist Dr Nick Kelland Consultant Cardiologist and Electrophysiologist Sheffield Teaching Hospitals Cardiac Update Debate

3 Disclosures Consulting: St Jude Medical. Travel grants: Medtronic; Boston Scientific; SJM. Educational support: Biosense Webster; Cooke Medical; Spectranectics. Speaker fees: Servier; Pfizer and Bristol Myers Squibb.

4 Atrial fibrillation Risk of stroke and death due to thromboembolism Severe symptoms of palpitation/ SOB Uncontrolled rate risks tachycardia related cardiomyopathy

5 What are the implications for stroke in an individual diagnosed with AF? 1 Lifetime risk of stroke after AF diagnosis up to one third 2 Hospital mortality 33% Vs 17% (RR 70%) 3 Hospital LOS 53.7 Vs 49.2days 4 Severe strokes (Barthel index) at 3m 58.3% Vs 16.3% 5 Discharge to nursing home 39% vs 25% 6 Mean cost of hospital stay 11,863 Vs 10,879 7 Higher long term support costs Watkins CL, Leathley MJ, Sharma AK. Stroke Interface Audit: Pre/post discharge audit of stroke services and care in Liverpool and Sefton: Delivery Timeliness and Targeting - 36 month report.

6 GP QOF database 2013/14 Register of AF patients (AF001) 6 Ref last accessed 12/2/15

7 GP QOF database 2013/14 Register of AF patients (AF001) 7 Ref last accessed 12/2/15

8 GP QOF database 2013/14 Register of AF patients (AF001) 8 Ref last accessed 12/2/15

9 QOF AF04 South Yorkshire and Bassetlaw CCG s 2013/ Ref - last accessed 12/2/15

10 QOF AF04 South Yorkshire and Bassetlaw CCG s 2013/2014 CCG Name Overall OAC Achievement rate if CHADS 2 >1 Barnsley 71% Bassetlaw 73% Doncaster 75% Rotherham 65% Sheffield 68% 10 Ref - last accessed 12/2/15

11 QOF AF04 South Yorkshire and Bassetlaw CCG s 2013/2014 CCG Name Overall OAC Achievement rate if CHADS 2 >1 Barnsley 71% Bassetlaw 73% Doncaster 75% Rotherham 65% Sheffield 68%..not doing a good enough job! 11 Ref - last accessed 12/2/15

12 SSNAP data October to December 2014 Ref; - last accessed 28th May

13 SSNAP data October to December 2014 Of those at highest risk low % of AF pts on OAC Ref; - last accessed 28th May

14 Anticoagulation for Stroke Prevention in Non-Valvular Atrial Fibrillation*: Joint primary and secondary care guidance This document provides guidance to primary and secondary care prescribers in selecting the most suitable anticoagulant for each patient and conducting appropriate baseline and ongoing monitoring. Where anticoagulation is commenced in secondary care, physicians are asked to send the Advice letter to GP to communicate the choice and reasons for selection. * Non-valvular AF is defined as AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. Patients with aortic valve disease are therefore included in the scope of this guideline. Do not wait for the results of any echocardiogram that may, or may not, be requested before anticoagulating. Echocardiogram will not affect the decision to anticoagulate. Step 1 Baseline investigations (page 2) Step 2 Assess stroke and bleeding risks (CHA 2 DS 2 VASc and HASBLED scores) (page 2) Step 3: Establish which anticoagulants would be appropriate (page 3) including consideration of drug interactions (page 4) Consider whether antiplatelets need to stop or continue (page 4).

15 AF risk of stroke Current rates of OAC use are too low Too many stroke pts, with history of AF, were not taking OAC at presentation Wider uptake of NOACs may help this see new S Yorks guideline New QoF set-up should result in clinical benefit Would greater involvement of secondary care in OAC pathway not improve anticoagulation rates?

16 72yo man Previously F+W HT Some knee pain - referred to orthopaedics for TKR Incidental/ asymptomatic AF referred to CRM clinic Rate 75bpm Echo: mild LVH with preserved systolic function AFEQT overall score =72 Symptom subscore = 95

17 72yo man Previously F+W HT Some knee pain - referred to orthopaedics for TKR Incidental/ asymptomatic AF referred to CRM clinic Rate 75bpm Echo: mild LVH with preserved systolic function AFEQT overall score =72 Symptom subscore = 95 RATE CONTROL + OAC Holter

18 Symptoms AF pts can be severely debilitated by Sx Options for rhythm control: Drugs (often need to be initiated in hospital) Ablation

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22 Pt we want to see for rhythm control Severely limited by symptoms clearly shown to be due to AF Limited comorbidities Willing to take small but significant risks of drug/ PVI to increase likelihood of SR

23 57yo man 2 episodes of sudden onset fast palps happened during water immersion (Helicopter emergency training) Documented paf CV with flecainide Structurally normal heart Normal MPS

24 57yo man 2 episodes of sudden onset fast palps happened during water immersion (Helicopter emergency training) Documented paf CV with flecainide Structurally normal heart Normal MPS MEDICAL THERAPY Given flecainide to use as required pill in the pocket

25 55yo man Previous RVOT VT/ VE ablation 2004 Now severe palpitations like a dark cloud Severe symptoms due to paf captured on Holter Structurally normal heart Flecainide and sotalol ineffective and caused bradycardia Rx with dronedarone but still disabling symptoms

26 55yo man Previous RVOT VT/ VE ablation 2004 Now severe palpitations like a dark cloud Severe symptoms due to paf captured on Holter Structurally normal heart Flecainide and sotalol ineffective and caused bradycardia Rx with dronedarone but still disabling symptoms AF ablation THERAPY Underwent Cryoballoon AF ablation with no attacks at 9 months.

27 58yo lady paf with severe symptoms Unable to work Structurally normal heart B blockers/ Flecainide ineffective Amiodarone caused hepatic aminases to rise Dronedarone caused severe nausea AF ablation THERAPY Underwent cryoballoon PVI AF ablation, without much benefit Redo point by point AF ablation under GA 12/12 post procedure, only very occasional and mild palpitations

28 AF-Symptoms AFIP/ NICE 2014 very low threshold for referral to a CRM specialist Most rhythm options require specialist input Suitable patients can get benefit from ablation if performed early enough

29 Rate control - Symptoms of dyspnoea/fatigue often due to uncontrolled VR

30 78yo lady Multiple comorbidity: TIAs; IHD; HT; obesity Severely dilated LA Permanent AF > 5yrs SOB on minimal exertion DC CV on AAD unsuccessful RATE CONTROL Likelihood of successful restoration of SR negligible

31 73yo lady paf with severe symptoms; presyncope/ TLOC Good LV function with large LA Mild PHT Systemic sclerosis + Reynaud s syndrome CHA 2 DS 2 VASc=2; HASBLED=1 Pace and AV node ablation Implant of DDD PPM, then AV node ablation. No more palpitations feels much more confident and independent

32 ATRIUM study High incidence of events many patients will need hospital care Compared to other studies pts under primary care have lower rate of CV, ablation as expected. Clinical Cardiolol 2014

33 High incidence of events many patients needed hospital care

34 ATRIUM study Compared to other studies pts under primary care have lower rate of CV, ablation as expected.

35 Extra capacity required in secondary care In STH 200 pts per year ie one clinic of 6 new pts per week, and one FU clinic. One extra Electrophysiologist In Rotherham 150 pts per year Pts could be automatically referred to the Specialist AF clinic, as soon as an ECG in primary care confirms AF.

36 Summary AF pts need higher rates of OAC this can be delivered by secondary care! Symptomatic patients cannot be effectively treated in primary care Patients with tachycardia related CM need specialist input

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41 Pt not needed to refer Multiple comorbidities AF is a consequence of other conditions: HT; obesity; mitral valve disease; sepsis; COPD; old age; HF. AF is not the primary problem if they were in SR their main limitations would remain

42 Could be more measured and alter motion All AF patients who need rhythm control should be referred to a CRM specialist Any AF pt with concerns/ issues over OAC should be referred to a CRM specialist

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