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Managing AF: A Look at Treating Specialty

Managing AF: A Look at Treating Specialty

About 2.3 million Americans are affected by atrial fibrillation and atrial flutter (AF), a condition that causes 15% of the 700,000 strokes that occur annually in the United States. Anticoagulants like warfarin can help prevent stroke in AF patients, but these therapies can also cause bleeding in some cases. “Prediction tools, such as the CHADS2 score, have been developed to estimate stroke risk and are now recommended by clinical guideline statements,” says Mintu P. Turakhia, MD, MAS. “These guidelines, however, vary considerably in describing how stroke and bleeding risk should be evaluated and integrated into clinical decision making.” Assessing Potential Variations in Warfarin Use It has been suspected that use of warfarin in AF may vary by specialty and over time. In the American Heart Journal, Dr. Turakhia and colleagues had a study published that evaluated differences and trends in warfarin prescription by treating specialty for new AF cases. Using VA data from the TREAT-AF study, the investigators reviewed more than 141,000 participants with newly diagnosed AF in which patients had at least one internal medicine, primary care, or cardiology encounter within 90 days of their diagnosis. The primary outcome was prescription of warfarin. According to results, care of patients with new AF from cardiologists appeared to be associated with a greater likelihood of warfarin prescription when compared with care only from primary care physicians (Table 1), even after adjusting for covariates and a propensity for cardiology care. The observation was also consistent across subgroups of patients, including those who were at lowest risk for bleeding. Furthermore, warfarin prescriptions were more frequently provided to those at highest risk for stroke,...
Key Concepts in Managing Afib

Key Concepts in Managing Afib

Atrial fibrillation (AFib) is the most common sustained heart rhythm disorder, affecting about 3 million American adults. The condition accounts for about 80,000 deaths each year in the United States, and its prevalence is projected to increase to 8 to 12 million over the next 30 to 40 years. “In addition to decreasing quality of life, AFib also dramatically increases the risk of stroke,” says Hugh Calkins, MD. The stroke rate among patients with AFib is increased about fivefold. Studies show that the likelihood of developing AFib increases markedly with age. Afib is rare prior to the age of 50, but its prevalence increases dramatically thereafter. By the age of 80, one in 10 individuals has AFib. It is the most common heart rhythm abnormality in people older than 65, and about 70% of AFib patients are between the ages of 65 and 85.  Other factors that increase the risk of developing AFib include male gender, hypertension, heart failure, family history, sleep apnea, and obesity. Making an AFib Diagnosis It can be challenging to diagnosis AFib because the signs and symptoms vary (Table 1). Some patients present with severe palpitations or presyncope, while others have no symptoms, with AFib first being detected on a routine physical examination. It is for this reason that the Heart Rhythm Society (HRS) encourages patients to check their pulse. If a patient detects a highly irregular pulse, a screening electrocardiogram (ECG) is advised. Continuous ECG monitoring systems are invaluable to detect AFib.               Guidelines recommend that patients who initially present with AFib be assessed using the CHA2DS2VASc risk...
ED Care of AF & Hospital Charges

ED Care of AF & Hospital Charges

The initial management of newly recognized atrial fibrillation and atrial flutter (AF) lasting over 48 hours is generally heart rate control along with anticoagulation to prevent future embolic events. Once rate control is achieved by emergency physicians, decisions on the timing of the rhythm control are often left to admission cardiologists. For cases in which AF duration is shorter than 48 hours, patients are often managed similarly. Recent studies, however, show that many of these patients can benefit from ED cardioversion (EDCV) to achieve normal sinus rhythm with discharge from the ED to home. Potential for Significant Savings In a study published in the Western Journal of Emergency Medicine, my colleagues and I examined 300 AF patients who came to the ED for care and were screened for timing of symptom onset. EDCV was considered if nursing or physician notes documented onset of AF symptoms within 48 hours of ED presentation in patients younger than 85. The median charges for EDCV patients were $5,460, compared with $23,202 for those admitted with no attempt at cardioversion. Median charges for patients whose final ED rhythm was normal were $5,641; for those remaining in AF, median charges were $30,299. A surprising finding from our study was that the resource savings produced by simply attempting EDCV, regardless of the results, were also significant. Admitted patients remaining in AF following cardioversion attempts still had hospital charges that were $8,628 lower than those admitted with no EDCV attempt. Efficient & Effective The longer a heart remains in AF, the more the atrium becomes conditioned to accept this rhythm. The sooner after the onset of AF...

ACC.11 & i2 Summit

Highlights from the American College of Cardiology’s 2011 Annual Scientific Session and Innovation in Intervention: i2 Summit 2011 include stenting following CABG, yoga reducing AF, restless legs syndrome linked to CVD, and RF ablation for atrial fibrillation.   » Restless Legs Syndrome Linked to Heart Problems » Stents & the Prevention of Major Adverse Events  » RF Ablation Beneficial for AF Patients » Lung Transplants & Atrial Flutter » Can Yoga Reduce Atrial Fibrillation Episodes?  Restless Legs Syndrome Linked to Heart Problems [back to top] The Particulars: As the population continues to age, there has been an observed increase in the prevalence of sleep-related disorders and cardiovascular disease (CVD). Some studies have suggested that there might be a correlation between restless legs syndrome (RLS) and CVD. The recognition of frequent periodic leg movement during sleep as a potential modifiable risk factor for left ventricular hypertrophy may offer another target to help reduce the burden of CVD and associated complications. Data Breakdown: A study was conducted in 584 patients who were referred to a sleep lab for polysomnography and had baseline echocardiography. According to electromyography, 45% of patients experienced more than 35 periodic leg movements per hour (the threshold considered severe). Patients with more than 35 bursts of leg movement per hour while sleeping carried a 1.85-fold elevated risk of severe left ventricular hypertrophy. When compared with those who did not have severe periodic leg movements during sleep, those who did had more evidence of structural heart problems, including, higher left ventricular mass on average, higher left ventricular mass index, thicker interventricular septum, and thicker posterior wall. Take Home Pearls: RLS characterized by...

Atrial Flutter: Current Concepts & Management Strategies

Typical atrial flutter (AFL), a condition which affects an estimated 200,000 new patients annually, has been defined as a pattern of regular tachycardia originating in the right atrium with an atrial rate of 240 beats/minute or higher. The current prevalence of AFL is high and is projected to increase considerably by 2050. Although not as common as atrial fibrillation, AFL can be a chronic condition. If left untreated, AFL can lead to debilitating symptoms, including shortness of breath, palpitations, dizziness, fainting, chest tightness, fatigue, and weakness. It can significantly impair quality of life and is associated with impaired cardiac output, atrial thrombus formation, and stroke. With proper treatment, however, AFL is rarely life threatening and symptoms can usually be managed effectively. “Atrial flutter is a common condition which should be treated appropriately to alleviate symptoms and prevent clot formation,” says Angelo Biviano, MD, MPH. Dr. Biviano adds that AFL in some patients can be associated with atrial fibrillation, and proper diagnosis and treatment is imperative. Research suggests that elimination of AFL may delay but not prevent fibrillation. Therefore, proper diagnosis and treatment of AFL is imperative. “The good news is that several treatment strategies exist for AFL,” says Dr. Biviano. “Consideration of patients’ medical history as well as their preferences will help guide treatment strategies for patients.” Identifying Causes AFL may be caused by abnormalities or diseases of the heart as well as diseases elsewhere in the body that affect the heart. These include diseases of the heart valves, especially the mitral valve, and chamber enlargement/hypertrophy. Diseases of the heart that have been linked to AFL include ischemia, atherosclerosis,...
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