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All you need to know about atrial fibrillation, blood clotting and stroke.

Charlotte Winn

on 28 March 2011

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Transcript of Cardiology

First, atrial fibrillation... Atrial fibrillation (AF) is a heart condition that causes episodes of irregular and often abnormally fast heart rate. There are 3 main types of atrial fibrillation: Paroxysmal atrial fibrillation
persistant atrial fibrillation
longstanding persistant atrial fibrillation How the heart works... Normally, the hearts muscular walls
contract to force blood to pump
around the body. They then relax, so
the heart can fill with blood again. But if you have AF, the atria contract randomly and sometimes so fast the heart doesnt have time to relax between beats. AF happens because abnormal impulses start firing in the atria - overriding the hearts natural pacemaker. AF is the most common heart
rhythm problem, affecting up to people in the uk. 500,000 AF is not life threatening. It can affect people of any age, but becomes more common as you get older.

However, it does affect more men than women. heartbeat over 140bpm
chest pains
Symptoms Some people have no symptoms. But... and AF is only discovered when undergoing routine tests or during investigations for another condition. What causes atrial fibrillation? high blood pressure
heart valve diease
congenital heart disease
pericarditis It is also associated with
other medical conditions: hyperthyroidism
lung cancer
pulmonary embolism
carbon monoxide poisioning Certin situations can trigger
an episode of AF: being overweight
drinking lots of caffine
drinking excessive amounts of alcohol - binge drinking If the doctor suspects AF, you may have an electrocardiogram or ECG. Electrorodes are placed on the body and attached to the ECG machine and this records the rhythm and electrical activity of the heart. Every little electrical signal is traced on paper through the ECG machane, and this can show any irregularities with the heartbeat. Diagnosis Or, an
may be used. This is an ultrasound
scan on the heart, which can help to identify other heart problems. echocardiogram Blood tests are also used to show anaemia, which may complicate the situation, or any problems with kidney functions or hyperthyroidism. Treatment Treatment of AF varies from person to person
and depends on: the type of atrial fibrillation
treatment of any underlying cause
overall health Some people may be treated by their GP, others may be referred to a cardiologist. The first step is to try and find out the cause of AF, and if a cause is found then the patients may only need treatment for this. If no underlying cause is found, the treatment options are...... Option One
Option two option four Option five These will restore a normal heartbeat or control the heartrate. To control the heartbeat to under 90 beats per minute a beta-blocker or a calcium channel blocker will be prescribed. Anti-arrhythmics to control atrial fibrillation Drugs prescribed may include:
diltiazem These restore a
normal heartbeat These control the
rate at which the
heat beats. Medicines to reduce
the risk of stroke. The way the heart beats with AF means that there is a risk of blood clots forming in the heat chambers. These blood clots may travel through the bloodstream into the brain, causing a stroke. The doctor will assess the risk and medicate accordingly. They will have to consider your age and if you have a history of:
stroke or blood clots
heart valve problems
heart failure
high blood pressure
heart disease Warfarin is often used to treat AF patients with a moderate-to-high risk of stroke. Warfarin is an
There is an increased risk of bleeding when taking warfarin, but the benefits usually outweigh the risks. anticoagulant. Patients with a low risk of stroke are likely to be given a low
dose of aspirin instead. Catheter Ablation This is a procedure that carefully distroys the diseased area of the hear and interupts the abnormal electrical circuits that cause AF. Thin, soft wires are guided throgh the veins, into the heart. When the abnormality is found high-frequency radio waves are transmitted to destroy the tissue. The procedure can take up to three hours, and is done under general anaesthetic. Cardioversion This is where the heart is given a controlled
electric shock to try and restore a normal
rhythm. If the patient is taking warfarin, this may be stopped if sucessful, depending on the risk of stroke. Pacemaker Option three This is a small battery operated device implanted in the chest to regulate heartbeats. It is a minor surgical procedure, done under local anaesthetic. Complications Stroke
Due to the increased risk of blood clots, the risk of a stroke in an AF patient is about double. If AF is persistant, it may start to weaken the hear leading to heart failure. Heart Failure Next stop: STROKE A stroke occurs when the blood supply to part of the brain is cut off. The brain needs the oxygen and nutrients provided by blood to function properly. If the supply of blood is stopped, brain cells begin to die. Strokes can lead to brain damage or death. What is a stroke? There are two main types of stroke: Ischaemic Stroke Haemorrhagic Stroke These occur when blood clots block the flow of blood to the brain. Blood clots typically form in areas where the arteries have been narrowed or blocked by fatty deposits. These occur when a blood vessel in the brain bursts and bleeds into the substance of the brain. There is related condition known as a transient ischaemic attack. This is where the blood supply to the brain in temporarily interrupted, causing a mini-stroke. They are often a warning system for a stroke. Every year in England over 150,000 people have a stroke. It is the third largest cause of death, after heart disease and cancer. The brain damage caused by strokes means that they are the largest cause of diasbility in the UK. People over 65 are most at risk, although 25% of strokes occur in younger people. Children can also have strokes. People who are South Asian, African or Caribbean have a higher risk of stroke, partly because of a predisposition to developing diabetes and heart disease. Symptoms: Strokes usually begin suddenly. As different parts of the brain control different parts of the doy, the symptoms will depend on which part of the brain has been affected. The face may have dropped on one side, they may not be able to smile or their mouth or eye may have drooped. They may not be abale to lift one of both arms and keep them there. The speech may be slurred or garbled, or the person may not be able to talk at all, despite being awake. These symptoms identify 9 out of 10 strokes. Other signs and symptoms may include: numbness or weakness resulting in complete paralysis of one side of the body
Sudden loss of vision
communication problems
difficulty swallowing
sudden and sever headache
blacking out The main causes of strokes... But strokes are largely preventable. Many key factors can be reduced by making lifestyle changes. Age: Family
history: ethnicity: medical
history: If a close relative has a stroke, the risk is likely to be higher If you have previously had a stroke, TIA or heart attack, the risk of stroke is higher. Ischaemic Strokes Smoking
high blood pressure
high cholesterol levels
family history of heart disease or diabetes
excessive alcohol Atrial fibrillation is also a possible cause. Haemorrhagic Strokes obesity
excessive alcohol
lack of excercise D
S CT Scan MRI Scan An MRI scan is used for patients with more complex symptoms and where the extent or location of damage is unknown. An MRI uses a strong magnetic field and radio waves to produce a detailed picture of the inside of the body. A CT scan is like an x-ray but uses multiple images to build up a detailed 3D image of your brain. If a major stroke is suspected then a CT scan is more likely to be used as it is quicker so the patient can be treated quicker. Swallow Tests Swallowing problems affect over 1/3 of stroke patients. When a person cannot swallow properly, there is a risk that food particles may get into the windpipe and lungs, which can lead to a chest infection and pneumonia. Sips of water are given to patients, followed by half a glass to see if they can swallow. If a person has any difficulty swallowing, they will be referred to the speech and language therapist for a detailed assessment. Heart and blood vessel tests Further tests may be carried out to confirm what caused the stroke. Ultrasound: Catheter
angiography: Echocardiogram: A wand-like probe sends high frequency sound waves into the neck to show if there is any narrowing or clotting in the arteries. Dye is injected into the carotid or vertebral artery to give a detailed view of the arteries via a CT or MR angiography. Produces images of your heart using an ultrasound probe placed on your chest. Treatment for ischaemic strokes using an 'alteplase' machine which dissolves clots *only effective it started within 4 1/2 hours of symptoms starting
anticoagulants - warfarin and heparin
blood pressure - if its too high, thiazide diuretic or angiotensin may be prescribed
statins to reduce cholesterol Treatment for haemorrhagic strokes Emergency surgery is often needed to remove any blood from the brain and repair burst blood vessels. This is done using a craniotomy which involves cutting away part of the skull to gain access to the brain. Recovery Damage from a stroke can be long lasting and very widespread. Many people need a long period of rehabillitation. A team of specialists are available, including:
occupational therapists
specialist doctors and nurses One third of people will make
an almost full recovery. One third of people will have a
significant amount of disability. One third of people will be severely affected and will die within a year. Complications Dysphagia Hydrocephalus DVT This is when patients have problems swallowing. To prevent further complications with food entering the windpipe, patients may be fed using a feeding tube, usually for up to six months. 5% of stroke patients will experience a blood clot in their legs. This normally occurs in people who have lost some or all mobility in their legs. Prompt treatment is needed, and can be treated with anti-clotting medicines. A condition that occurs when there is too muich cerebrospinal fluid in the cavities of the brain. A symptom of this is severe headaches. It can be treated by using a tube in the brain to allow fluid to drain properly. And finally.... Blood clotting (or as it is sometimes known, thrombosis) Thrombosis Thrombosis is the clotting of blood within a blood vessel It occurs when a blood clot blocks a vein or artery, obstructing or stopping the flow of blood. There are two main types of thrombosis:
Venous thrombosis - a clot which develops in a vein
arterial thrombosis - a clot which develops in an artery Deep Vein Thrombosis (DVT) is one of the most common types, which is a blood clot in the lower legs. This mainly affects people after a period of immobility, such as a long flight or when recovering from an illness. Sometimes a blood clot can detach from its orignial site and travel through the blood stream. This is known as an embolism. 1 in every 1,000 people are affected by venous thrombosis. Anyone can be affected, although it becomes more common with age. A blood clot which lodges in the lungs is called a pulmonary embolism. S
S But thrombosis often has few or no symptoms. Symptoms will depend on the location of the blood clot, and what type it is. Venous thrombosis symptoms: pain, swelling and redness at the blood clot site
heavy ache in the affected area
an itchy skin rash in the area of the clot
warm skin in the affected area
prominant veins that stand out
mild feaver If it is a pulmonary
embolism there may be: breathlessness
pain in the chest
sudden collapse Arterial thrombosis can cause: heart disease
heart attack
peripheral vascular disease Each of the conditions which happen with arterial thrombosis have their own set of symptoms. Causes of blood clots Blood contains cels called platlets and clotting factors (proteins), which make up the blood clotting mechanism. When a blood vessel is cut, the platelets and clotting factors mesh together to form a solid clot at the site of the wound. This acts as a plug to stop the bleeding. Normally, this only happens when a blood vessel is damaged and bleeds. Sometimes the blood may start to clot when the blood vessel hasnt been damaged. If this happens, a blood clot can form within a vein or artery. The main risk factors for thrombosis are: Getting older
being inactive or immobile for long periods of time
having a previous blood clot
having a previous heart attack or stroke
having a member of family with a blood clot
taking the combined contraceptive pill or HRT
a condition such as thrombophilia that makes blood more likely to clot
high blood pressure
high cholesterol
poor diet
having an operation on the lower half of the body Diagnosis D-dimer blood test Doppler study Venogram Several tests may be used to diagnose thrombosis. This is a blood test used to find out if the body has been working to break down a blood clot. If it hasnt, it is unlikely there is a clot. If it has, then another test will be need to confirm. This is used to measure the supply of blood in each leg. Blood pressude will be taken in each ankle and compare it with the blood pressure in the arm. When the measurements are compared, they can show whether or not the blood supply in the legs is reduced due to a blood clot. This a a type of x-ray that uses dye to highlight a blood clot in a blood vessel. The dye will be injected into a vein in the foot, which travels up the blood vessels of the leg. An x-ray is then taken to show the blood vessels in the leg. If there is a clot, the dye will not be able to dlow round it, and will show as a 'gap' in the blood vessel. If the doctor thinks there may be a pulmonary embolism, further tests may be carried out.... Ventilation Scan CT Angiogram This uses dye to show the presence of a blood clot in the lung. This shows the amound of air and blood flow in the lungs. If there is a part of your lung that has air in it, but no blood, it may be due to a pulmonary embolism. Treatment for venous thrombosis Anticoagulants, such as heparin or warfarin are usually prescribed. These thin the blood, preventing blood clots from getting any bigger. They can also stop the clot from breaking off and becoming an embolism. Heparin - this is usually given first because it works immediately to prevent further clotting. Heparin is given intravenously.
There are two forms of heparin: standard and low-molecular-weight. Standard heparin has to be given in hospital as the dosage may need to be adjusted. Low-molecular-weight heparin is more reliable and it is unlikely a hospital stay is needed. Warfarin - this is taken in tablet form. It may need to be taken after the initial heparin treatment to prevent further blood clots. Regular blood tests may be required until the correct dosage is decided. Treatment for venous thrombosis To prevent future blood clots occuring, there may also be treatments for an underlying condition. Anti-platelet medicines help to stop the blood clotting so that a blood clot in an artery doesnt get any bigger. Asprin is the most common. Surgery may be needed to clear arteries that are severley blocked, and to prevent the clot returning. Blood pressure medicines may be prescribed to lower blood pressure. This will help to prevent fatty deposits building up inside the arteries, which in turn, will prevent blood clots forming. Thiazide diuretic or ACE inhibitors are common. Statins such as atorvastatin and fluvastatin help to lower cholesterol in the blood. Cholesterol is a type of fat that sticks to the walls of the arteries, making them narrower and increasing the risk of blood clots.
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