Case Study on Artril Fibrillation

Question: Describe about the Case Study on Artril Fibrillation? Answer: Mrs. SS is suffering from persistent atrial fibrillation, which is also known as cardiac arrhythmia and is characterized by irregular RR intervals. There are no proper P waves on the surface ECG. Although if the patient shows signs of irregular pulse, AF can be detected but for confirmation and diagnoses an ECG recording is necessary. The progression of AF moves from short- rare episodes to longer-frequent episodes 1. In case of Mrs. SS, AF is persistent with the ventricular rate of 125 bpm. The initial management of AF is done by noting down the patient medical history with respect to the known AF and this is followed by the relief of symptoms and assessment of the risk that is associated with the disorder. The clinical evaluation process involves the determination of EHRA (European Heart Rhythm Association) score of the AF symptoms, degree of stroke risk, associated complications of arrhythmia and the conditions that pre dispose to Atrial fibrillation 1. The preventive measures of AF related complications include antithrombotic therapy, control and regulation of ventricular rate, etc 2. The rate control and rhythm management in patients with AF is the main focus area. Sinus rhythm management is generally done using the antiarrhythmic drugs but the side effects of these drugs are more as compared to the benefits. Another therapy used is the electrical cardioversion, but the frequent recurrences of AF has decreased the benefits associated with this therapy. Now since rhythm is not the major determinant of the prognosis of AF, the debate on which is better- ventricular rate control or rhythm control, is still on. In a research by 3, the results concluded that in patients like Mrs SS, who supper from hypertension, the rhythmic control often lead to events of cardiovascular origin and thus, ventricular rate control should be considered at a more early stage in the process of management of AF 3. For Mrs. SS, rate control is preferred over rhythm control because if rhythm control is associated with prevention of tachycardia or heart failure, then rate control can also help in preventing failure of heart. Secondly, in the research it has been shown that rhythm control is believed to reduce the risk of stroke, the patients may even then suffer from stroke after the anticoagulant therapy ceases even though the sinus rhythm is being maintained. Thirdly, since the patients with persistent atrial fibrillation are at a continued risk of stroke, the anticoagulant therapy can be stopped in some rare cases. Now rhythm control is believed to reduce the risk of bleeding that results after discontinuation of anticoagulation therapy. But if the therapy can be seldom stopped, the sinus rhythm will not be able to control the risk of bleeding 3. The pharmacological therapy for prevention of AF is based on the use of ACE inhibitors and the angiotensin receptor antagonists. This is because the ACE inhibitors reduce the atrial pressure and thereby reduce the frequency of the premature atrial beats, decrease fibrosis and may also reduce the relapse after the cardioversion. These drugs are known to reduce the signal averaged P wave duration and also reduces the number of defibrillation attempts that are needed to restore the rhythm of the sinus. Some of the drugs that fall under this class are Ramipril, Captopril, Zofenopril, etc. Since Mrs. SS is also suffering from hypertension, ACE inhibitors can help in treatment of hypertension too. The medication list shows that Ramipril is being given to Mrs. SS, which is a dicarboxylate containing drug 2. Since Mrs. SS also reports type 2 diabetes, she has to be given Janumet, which is a combination of metformin and sitagliptin and is a oral diabetes medication 4. Another drug that is use d in the treatment of hypertension in Mrs SS, is Indapamide, which is a diuretic and oral antihypertensive drug. Atrial fibrillation is a condition that is accompanied with increased risk of stroke that might be thromboembolic. Warfarin is the preferred anticoagulant therapy that is used for prevention of embolic stroke 5. But long term use of warfarin has its limitations. Therefore, another anticoagulation agent, which is Non Vitamin K antagonist Oral anticoagulant (NOAC) can also be used for the anticoagulation therapy in Mrs. SS. Basically two main options are present fo prevention of stroke. One is the anti coagulation therapy and the other is the use of aspirin in treatment and prevention of stroke. The research based studies prove the efficacy of anticoagulation therapies in preventing stroke as aspirin is linked with the occurrence of intracranial haemorhage 6. For a long time oral Vitamin K antagonists were being used for preventing embolism and warfarin was the most commonly used VKAs. This treatment is safe and effective and can help in achieving a stable level of anticoagulation. However, there are certain limitation like the sensitivity of this antagonists towards food items and other drugs that may alter their pharmacokinetics. The anticoagulation control is also poor leading to frequent thrombolic events or even increased risk of bleeding including haemorhage which is intracranial. To avoid this kind of misuse of the VKA, newer antagonists called NOAC were identified. The anticoagulant that falls under this category is dabigatran exexilate which is considered potent enough to inhibit thrombin, apixabin and rivaroxaban, all of which inhibit factor Xa.One of the distinguishing feature of NOACs is that they target a specific coagulation enzyme- either factor Xa or thrombin 7. On the other hand VKAs are known to simultaneously lower the levels of multiple coagulation factors. Therefore, in case of Mrs SS, non Vitamin K antagonist oral anticoagulants (NOAC) should be preferred. Although no forms of antidotes are available for NOAC that could help in the management and assessment of the life threatening bleeding problem, but some of the specific antidotes are in the early development phase. The NOACs have variable consequences for usually accessible schedule tests of coagulation, which can in some cases confuse evaluation of their anticoagulant action 8. References 1. Camm, J., Kirchhof, P., Lip, G. et al. Guidelines for the management of atrial fibrillation. European Heart Journal [Internet]. 2010[cited 2015 February 9].2. Fuster, V., Ryden, L., Cannom, F. et al. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. Journal of MAerican College of Cardiology [Internet]. 2011 [cited 2015 February 9]; 57(11):e101-e198.3. Gelder, I., Hagens, V., Bosker, H. et al. A Comparison of Rate Control and Rhythm Control in Patients with Recurrent Persistent Atrial Fibrillation. The New England Journal of Medicine [Internet]. 2002 [cited 2015 February 9]; 347:1834-1840.4. Reynolds, J., Neumiller, J. and Campbell, R. Janumet: a combination product suitable for use in patients with Type 2 diabetes. Expert opinion on investigational drugs [internet]. 2008 [cited 2015 February 9]; 17(10): 1559-1565.5. Zoppo, G. and Eliasziw, M. New options in anticoagulation for atrial fibrill ation. The New Englang Journal of Medicine [Internet]. 2011[cited 2015 February 9].6. Mant, J., Hobbs, R., Fletcher, K. et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. The Lancet [Internet]. 2007[cited 2015 February 9]; 370(9586): 493-503.7. Eikelboom, J., Connoly, S., Brueckmann, M. et al. Dabigatran versus Warfarin in Patients with Mechanical Heart Valves. The New Englang Journal of Medicine [internet]. 2013[cited 2015 February 9]; 369:1206-1214.8. Husted, S., Caterina, R., Andreotti, F. et al. Non-vitamin K antagonist oral anticoagulants (NOACs): No longer new or novel. Editorial [Internet]. 2014 [cited 2015 February 9].