About Stephen Dorman
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Excellent presentation. It would be helpful to know if anticoagulation is beneficial in those with infrequent attacks of AF (given the results of the KP Rhythm study) and in those who have had a successful ablation. Thank you. Stephen Mort.
Thanks Stephen – great question
The official answer from the European Society of cardiology guidelines is “The threshold of AF burden at which to initiate OAC therapy needs to be defined more clearly. This knowledge gap has resulted in substantial variation in physician attitudes and practice patterns”
Essentially we are waiting for the results of 2 RCT’s in subclinical AF patients ( CIED & NOAH) to try and answer this question.
Generally speaking there is consensus that;
1. For individuals with asymptomatic AF detected on implantable devices GREATER THAN 24 HOURS in duration the stroke risk approaches that of clinically diagnosed AF and so anticoagulation should be considered.
2. For episodes of asymptomatic AF LESS THAN 5 MINUTES detected on implantable devices the stroke risk appears to be minimal.
3. For episodes between 5 minutes and 24hoursreasonable to use AF duration and CHADS VASC to inform the decision on anticoagulation
The more you read the more complex it becomes .
I would recommend the following article “It’s time to rethink ( and retrial) our framework for stroke prevention in atrial fibrillation” – Turakhia JAMA Cardiolo Sept 29 2021 which challenges a lot of long held assumptions
Regarding whether or not you need anticoagulation post AF Ablation most EP doctors would recommend you continue to be guided by the CHADS VASC score.
Hope that helps provide some insight into the many unknowns of this area
Following ablation, if successful in restoring sinus rhythm, do patients need to continue with anticoagulation as indicated by the CHADSVasc score?
Most people feel you should continue anticoagulation ( if indicated by CHADSVasc) , even if ablation is successful. There may be a small number in the EP community who would feel it might not be needed in selected cases but that would not be generic advice
Excellent update and interesting to hear the interventional cardiologist disagree with NICE in relation to early referral for ablation in symptomatic younger patients whose QOLY is affected.
I had successful ablation 6 years ago in Leeds and it has transformed my QOL!
Dr SD GP Nottinghamshire
Thanks very much - a big topic to cover in 20 minutes and completely agree with your comment about the transformative effect of ablation in younger symptomatic patients. As always case selection for an interventional procedure is key and there is no doubt well selected patients do extremely well, so no issues with early referral for this group.
A helpful overview of the Ischemia Trial. Under current Covid restrictions we are not able to send patients for ETT in my area, where the system set up does not have capacity for many CT-angiograms; thus we have reverted to medicine that we practised 20 years ago & if history suggests angina we are (at the request of our cardiology colleagues) initiating & optimising medical treatment in Primary Care. Naturally this applies to stable angina, with those exhibiting unstable angina being seen by cardiology. You make a great point about LAD disease +/- LVF doing better with intervention. Ischemia was a worthwhile trial in our current medico-economic climate.
Rebecca Wheater, GP & Co-Chair of SHARP, Tayside
Thanks Rebecca - You are quite correct that most hospitals are very unkeen on doing treadmill tests currently due to the Covid situation and CT capacity is better in some areas than others. The main value of the CT Coronary angiogram is to quantify the extent of disease and exclude LMS disease. If you can't access the right tests then initiating & optimising medical therapy is a very reasonable and pragmatic response. I think we have come full circle from highly sophisticated ischaemia testing to going back to ask the patient about their symptom burden. A high symptom burden is actually a pretty good guide to the need for intervention.