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AFter all’s said and done
By
Kevin Kulendra
Abigail Hoyle
Thomas Bean
Iram Yasin
Sharon Wong
Chris Oscier
History
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Mr GC – 79yr old male (Retired Laundry Worker) [seen on 08/07/03]
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PC – Cold & Painful R. Hand
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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
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PMH – Hypertension for 1 year
- BPH
- Appendicectomy (‘47)
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DH – Adalat 60mg od
- Ramapril 2.5 mg od
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FH – NAD / No Children
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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
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SE – CVS – hypertension
RS – Dry Cough
GIT – Diarrhoea (3/7 ago)
GUS - NAD
MSS - NAD
CNS - NAD
Examination
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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
 New
Diagnosis;
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.
Investigations
 Temp
37.0°C, BP 167/90mmHg, P 82bpm, RR 24bpm,
Sats 96% on air, Glucose 5.7, GCS 15.
 Urinalysis - NAD
 ECG - AF, ?u waves (no indicators of an MI)
 Troponin T <0.01
 Doppler Pulses - normal on Left side, reduced on Right
side.
Management
 Anticoagulation
 Following
 Limb
Heparin 5,000 i.u. S.C.
reassessment post anticoagulation
still cold (>12 hours after Heparin), ischaemic, without
palpable pulses
 Refer to the surgical team for Right Brachial Embolectomy
 Operation 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 AntiCoagulation Therapy.
Acute Limb Ischaemia
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Affects upper and lower limb (amputation rate 16%,
mortality 22%)
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Differential diagnosis
Thrombosis in situ (40%)
 Emboli (38%)
 Graft/angioplasty occlusion (15%)
 Injury
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Clinical Presentation
6
P’s
 Pain
 Pulseless
 Perishing
with cold!
 Pallor
 Paraesthesia
 Paralysis
Sources of emboli
 Mural
thrombus of right atrium + AF
 Previous MI
 Rarer sites
 Valves
 Ventricular
aneurysm
 Atrial myxoma
 Atheromatous plaque
Management
Arteriography if diagnosis is uncertain
 iv heparin
 Embolectomy – Fogarty Balloon catheter
 Local thrombolysis – t-PA
 May need reconstruction
 Search embolic source
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Echo
 USS
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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
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Aetiology of AF
COMMON
 Heart Failure
 Hypertension
 Cardiac Ischaemia
 MI
 Mitral Valve Disease
 Pnuemonia
 Hyperthyroid
 Alcohol
RARE
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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
 Commonly
Presentation
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 AF
Chronic AF
•Maybe Self-limiting
•Anticoagulate with IV Hep ±
warfarin
Sustained AF
•Treat compliactions
•Consider rate control or
cardioversion
Persistent AF
Paroxysmal AF
•Aim is to  paroxysms and
maintain sinus rhythm
•Consider anti-thrombotic
therapy
•In resistant cases, consider
non-pharmacological
methods
•Aim is to cardiovert to sinus
rhythm
•Anticoagulate
•Consider anti-arrythmic
therapy to maintain sinus
rhythm post cardioversion
Permanent AF
• Aim is heart rate control and
thromboprophylaxis
•Consider drug for rate control
•Consider warfarin or aspirin
•In resistant cases, consider nonpharmacological methods.
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
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Previous thromboembolism
Left atrial enlargement
AF associated with:
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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
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Pregnancy
Peptic ulcer disease
Severe hypertension
Bacterial endocarditis
Non-thromboembolic stroke
Haemostatic defect
Caution with:
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Hepatic and renal disease
Recent surgery
Breast feeding
MECHANISM OF ACTION
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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)
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DOSE
AND
INTERACTIONS
Induction 10mg daily for 2 days
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Subsequent maintenance depending on prothrombin ratio
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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
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Decreased metabolism:
Increased hepatic sensitivity:
Decreased vit. K absorption:
Displacement from albumin:
Platelet inhibition:
Potentiation:
TADs, cimetidine, phenothiazines, amiodarone
clofibrate, quinidine
broad-spectrum antibiotics, cholestyramine
sulphonamides
aspirin
alcohol xs (heart failure, liver/renal disease, thyrotoxicosis, fever)
A DECREASED ANTICOAGULANT EFFECT DUE TO WARFARIN
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Increased clearance by hepatic enzyme induction:
rifampicin and barbiturates
Thank You