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Atrial Fibrillation. You are a GP in surgery. Your next patient is Chris Woodward, aged 55. He had a transient ischaemic attack two years ago and takes 75 mg aspirin daily. You have been monitoring his blood pressure after a couple of high readings, but this seems to have settled for now.
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Atrial Fibrillation You are a GP in surgery. Your next patient is Chris Woodward, aged 55. He had a transient ischaemic attack two years ago and takes 75 mg aspirin daily. You have been monitoring his blood pressure after a couple of high readings, but this seems to have settled for now. However, a week ago when you were checking his blood pressure you thought he was in atrial fibrillation. An ECG has now shown this.You have asked Chris to come back today to discuss anticoagulation.
You are Chris Woodward. You are 58 and work as a clerk for a large City firm. You live in a block of flats near the town centre. You have never married and your only child is now married with a daughter of her own. You adore your grand-daughter, and help out with her care whenever you can. You left school at 14 to start earning money, which was encouraged. You smoke 10 cigarettes a day and binge drink on Fridays and Saturdays with your friends. • You have been seeing your GP regularly, and have become really frightened that there is something seriously wrong. First he seemed worried about your blood pressure and now he is concerned about your pulse. You have been panicking and not sleeping. You think there must be something terrible happening to your heart. You are especially worried because of a frightening mini-stroke (warning stroke) two years ago. You had investigations at the time but no cause was found. Since then you have been advised to take a small dose of aspirin daily as prevention. • The doctor wants to see you again today to discuss whether to start a "blood thinning" tablet called warfarin. You tried to read the leaflet you were given, but could not understand it. A friend has told you that warfarin is "rat poison." You also think this is what your aunt was put on after a stroke. She fell down her front steps and subsequently died of a bleed on the brain.
Another way to stratify risk - Risk stratification and anticoagulation in non-valvularatrial fibrillation Assess risk, and reassess regularly: • High risk (annual risk of CVA=8–12%) •All patients with previous transient ischaemic attack or cerebrovascular accident. •All patients aged 75 and over with diabetes and/or hypertension. •All patients with clinical evidence of valve disease, heart failure, thyroid disease, and/or impaired left-ventricular function on echocardiography.* *Echocardiogram—not needed for routine risk assessment but refines clinical risk stratification in case of impaired left-ventricular function and valve disease (see 1 above). A large left atrium per se is not an independent risk factor on multivariate analysis.
Another way to stratify risk - 2 Moderate risk (annual risk of CVA=4%) •All patients aged under 65 with clinical risk factors: diabetes, hypertension, peripheral arterial disease, ischaemic heart disease. •All patients over 65 not in high-risk group. • Low risk (annual risk of CVA=1%) •All other patients under 65 with no history of embolism, hypertension, diabetes, or other clinical risk factors.
Or CHADS2 = 1 point for CCF, hypertension, age over 75, DM and 2 for previous stroke /TIA Table 3. Relative thromboembolic risks of oral anticoagulation (OA) therapy with warfarin in a large primary-care network, by CHADS2 score
