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.
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.
Risk stratification and anticoagulation in non-valvularatrial fibrillation Assess risk, and reassess regularly:
•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.
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.
•All other patients under 65 with no history of embolism, hypertension, diabetes, or other clinical risk factors.
Table 3. Relative thromboembolic risks of oral anticoagulation (OA) therapy with warfarin in a large primary-care network, by CHADS2 score