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Management of Atrial Fibrillation                                                          ♦    Assess the need to convert to sinus rhythm


Causes of Atrial Fibrillation                                                              Physical Exam
Cardiac           ♦    Valvular dz – MR, MS             ♦   Sick sinus syndrome            ♦    confirm AF (4 signs)
                  ♦    IHD                              ♦   Post-cardiac surgery                     o IR IR pulse
                  ♦    HPT                              ♦   Peri-/myo-carditis                       o Single flicker JVP - absence of ‘a’ wave
                  ♦    Post MI                          ♦   Pre-excitation syndrome                  o pulse deficit
                  ♦    CCF                              ♦   Acute pul. Embolism                      o varying loudness of 1st heart sound
                  ♦    ASD                              ♦   Lone AF (no known              ♦    signs of underlying causes of AF– BP, goiter and signs of thyrotoxicosis,
                  ♦    Cardiomyopathy                       etiology or structural heart        auscultation for murmurs (MR/MS)
                                                            dz. Dx of exclusion)
                                                                                           ♦    complications – CCF, previous stroke
Non-Cardiac       ♦    Hyperthyroidism                  ♦   DM
                  ♦    Sepsis esp pneumonia             ♦   Alcohol
                                                                                           Investigations
                                                                                           ECG                    ♦ to document AF, any evidence of MI, LVH/LAH
Morbidities of AF                                                                          CXR                    ♦ chamber size, heart failure
♦   ↓ cardiac output – malaise and effort intolerance
                                                                                           FBC
♦   aggravation of MI and heart failure
                                                                                           U/E
♦   ↑ risk of Thromboembolism and stroke
                                                                                           TFT                    ♦ hyperthyroidism
                                                                                           Transthoracic          ♦ structural HD (CMP, valvular dz, intracardiac shunt, pericardial
Types of AF:                                                                               echocardiogram           HDz),
♦   1st detected episode - may not need tx if episode is brief/ known reversible cause     (TTE)                  ♦ chamber sizes
♦   Acute AF – detected within 24-48h, has high chance of pharm/electrical cardioversion                          ♦ LV size and function.
♦   Paroxysmal AF – AF lasting less than 7 days                                            Additional Invxs
♦   Persistent AF – >7 days                                                                24h Holter             ♦   Quantify freq & duration of symptomatic & asymp. AF episodes
♦   Permanent AF – previous attempts to restore sinus rhythm have failed/ AF lasted >1y.                          ♦   Look for sinus node dysf(x) or sick sinus syndrome
    The probability of successful cardioversion is very low                                                       ♦   Assess adequacy of rhythm or rate control
                                                                                                                  ♦   Assess time of onset of AF (eg night in vagally-mediated AF)
Clinical Presentations                                                                                            ♦   Identify PTs with frequent atrial ectopics & nonsustained atrial
♦   Palpitations                                                                                                      tachycardia suitable for catheter ablation
♦   CP                                                                                     Transesophageal        ♦   Gives better visualization of LA thrombus cf TTE)
♦   Dyspnoea                                                                               echocardiogram         ♦   Use before elective cardioversion in PTs w/o prior 3wks
♦   Fatigue                                                                                (TEE)                      warfarin
♦   Light headedness                                                                       Exercise stress test   ♦   Assess PT with AF ppted by exertion, IHD or MI
♦   Syncope                                                                                                       ♦   Routinely done for PTs ≥40YO or with significant coronary risk
♦   Cxs of AF – heart failure, haemodynamic impairments, stroke                                                       factors.
♦   Asymptomatic (25%)                                                                     Electrophysiological   ♦   For PTs w hx of syncope to exclude sick sinus syndrome and
                                                                                           study (EPS)                Wolff-Parkinson-White syndrome
Evaluation of AF
♦   stable or unstable                                                                     Management of AF:
♦   confirm diagnosis of AF with 12 lead ECG                                               ♦    Aims:                                                      • Improve symptoms
♦   classify type of AF                                                                             o     Control ventricular rate                         • Reduce TE stroke risk
♦   determine underlying cause/factors contributing to AF (eg structural and ischaemic              o     Reestablish sinus rhythm                         • Prevent cardiac remodeling
    HDz, estimating LVEF, valvular HDz, CMP, HPT)                                                   o     Anticoagulate to prevent Thromboembolism           and hence HFailure & CMP
♦   look for complications of AF
♦   determine risk of future complications, i.e. stroke, from AF                           Unstable:
         o     HTN/ old age/ IHD/ heart failure / previous stroke/ DM                                o    immediate sync. Cardioversion
♦   Assess adequacy of control of ventricular rate during AF                                         o    f/u with anticoagulation therapy for 4 weeks
Stable:
     a) Acute AF (<48h)
     ♦       Can be cardioverted (pharm/electrical) without prior long-term anticoagulation          Rhythm Control:
     ♦       Give IV heparin before proceeding                                                       ♦    Spontaneous cardioversion occurs in 50-70% of PTs w/in 24 to 48 hrs, but unlikely to
     ♦       And switch to oral, maintain INR at 2-3 for 4 weeks whatever the outcome                     occur if AF persisted for > a week. Drug/electrical cardioversion will be necessary.
                                                                                                     ♦    Success rate of cardioversion decrease as duration of AF increase, therefore perform
     b) Persistent/ Recurrent Paroxysmal AF                                                               early
     If minimal symptoms,                                                                            ♦    Problems: failure in maintenance of sinus rhythm in >50% of PTs, significant SE of
           1) Rate control                                                                                drugs used
                o    Beta-blocker
                o    Ca blockers e.g. diltiazem/ verapamil                                           ♦     Pharmacological Cardioversion:
                o    Digoxin (esp if concurrent HF)                                                      Drug                    Comments                                SE
                o    Sotalol                                                                             Class IC arrhythmics    ♦ Contraindications                     ♦ conversion to atrial flutter
           2) Assess for risk of thromboembolism and anticoagulate as necessary                          (propafenone 300-           - IHD                               ♦ ventricular tachycardia
     This is the recommended management for most patients, unless acute onset (<48h), or                 600mg PO stat,              - CCF                               ♦ enhanced AV nodal
     symptomatic, or complicated                                                                         flecainide150-200mg         - Lt vent dysf(x)                      conduction
                                                                                                         PO stat)                    - major conduction                  ♦ CCF
                                                                                                                                       disturbances
     c) Symptoms/ complications (e.g. syncope, heart failure, stroke)
                                                                                                         Amiodarone              ♦ Takes days to wks for onset           ♦   Hepatotoxic
     ♦       Rate control initially followed by cardioversion, with anticoagulation
                                                                                                         (600-800mg/day PO)      ♦ Safe for PT with structural heart     ♦   Thyroid dysfunction
     ♦       Then,
                  o    anticoagulate for 3 weeks with warfarin (keep INR 2-3) before cardioversion
                                                                                                                                   dz or heart failure                   ♦   GI upset
                                                                                                                                 ♦ Monitor LFT & TFT 6 mthly for SE      ♦   Bradycardia
                             ♦      Amiodarone
                             ♦      Flecainide                                                                                                                           ♦   Torsades de pointes
                             ♦      Propafenone                                                                                                                          ♦   polyneuropathy
                  o    Alternatively, do TEE to look for LA thrombus. If none, give IV Heparin and       Dofetilide & ibutilide                                          ♦
                       perform DC cardioversion w/o prior anticoagulation.                               Quinidine                                                       ♦   Hypotension
     ♦       Post cardioversion, maintain INR at 2-3 for 4 weeks                                                                                                         ♦   Torsades de pointes
     ♦       Maintenance of sinus rhythm (Flecainide, propafenone, sotalol, amiodarone)                  Sotalol                  ♦ NOT for cardioversion                ♦   Torsades de pointes
                                                                                                                                  ♦ Only for maintaining sinus rhythm    ♦   CCF
                                                AF                                                                                                                       ♦   Exacerbation of COPD

                                                                                                     ♦    Electrical cardioversion:
                  Unstable                                                    Stable                      o    PT must be fasted and sedated, with good IV access and airway Mx
                                                                                                          o    Check electrolyte and anticoagulation status
             ♦ Sync cardioversion                                                                           Monophasic AF                       200 joules, increments up to 360 joules
             ♦ 4 wks anticoagulation                                                                                        Atrial flutter      50 joules
                                                                                                            Biphasic        AF                  100 joules initially
                                                                                                          o    Cxs: Thromboembolism, arrhythmia, myocardial injury, heart failure, skin burns.
                 st
                1 episode / Acute AF (<48hrs)                      Persistant / recurrent
                                                                     paroxysmal AF                   ♦    Other non-pharmacological rate control therapies
♦ Pharm / electrical cardioversion w/o prior anticoagulation                                              o   Permanent Pacing
♦ 4 wks anticoagulation                                                                                   o   Catheter ablation – for PTs with paroxysmal AF due to atrial ectopics, PT with
♦ long-term anticoagulation not necessary                                                                     SVT or atrial flutter
                                                                                                          o   Surgical ablation – “Maze” procedure: consider concomitant Sx ablation in PTs
                                                                                                              going for open heart Sx for valvular, ischaemic or congenital heart dz.
                  Asymptomatic                              Symptomatic / complicated
                                                                                                     ♦    Maintenance of Sinus Rhythm
             ♦ Rate control                           ♦ Rate control & anticoagulation                    o   Flecainide, propafenone and sotalol are first line drugs
             ♦ Long-term anticoagulation              ♦ Cardioversion & maintain sinus rhythm             o   Amiodarone superior to previous drugs, but last choice of drug due to long term
                                                      ♦ Long term anticoagulation                             extracardiac SE.

         •     Treat ppt factor if present
         •     Failure of drug therapy to achieve rate control or maintain sinus rhythm – consider
               pacemakers, defibrillator or catheter ablation
o    Choice of drug in heart dz:
                 Heart failure: use amiodarone                                               ♦    Contraindications to anticoagulation
                 CAD: use sotalol                                                                  ♦    Significant bleeding or fall risk        ♦     PT unlikely to comply with diet &
                 HPT with LVH ≥1.4cm: use amiodarone                                               ♦    Recent surgery / trauma                        monitoring regimen
                                                                                                   ♦    Thrombocytopenia                         ♦     Active peptic ulcer dz
Rate Control:
♦    Similar efficacy to rhythm control, but drugs used are safer and there is no problems   ♦    Antithrombotic strategies
     wrt maintenance of sinus rhythm                                                               Any high-risk factors present      Long-term oral anticoagulation (target INR2.5;
♦    Pharmacological rate control:                                                                 >60YO with one other               range 2.0-3.0)
    Drug                       Comments                      SE                                    moderate risk factor
    β-blockers                 ♦ First line Rx               ♦ Bronchoconstriction. CI in          <60YO + one moderate risk          Either aspirin 100mg/day or warfarin depending on
    (propranolol, atenolol,    ♦ Caution in PTs with heart       asthma                            factor                             PT preference, risk of blding and access to
    sotalol)                     failure                     ♦ Heart failure                       60-75YO with no risk factor        anticoagulation monitoring
                                                             ♦ Hypotension                         Male >75 with no risk factor
                                                             ♦ Heart block                         Low risk or warfarin is CI         Aspirin (100-300mg/day). Alternatives: ticlopidine,
                                                             ♦ Bradycardia                                                            clopidogrel, dipyridamole
    CCB (verapamil,            ♦ IV CCB useful in            ♦ Hypotension                         <60YO with no risk factors &       Long term aspirin or no Rx
    diltiazem)                   emergencies                 ♦ Heart block                         normal left atrial size
                               ♦ Preferred over β-blockers ♦ Heart failure                   *always consider PT factors in determining target INR level (eg fall risk in elderly, recurrent
                                 in PT with COPD                                             TE events despite anticoagulation, prosthetic heart valves) & modify Rx accordingly
                               ♦ Caution in PTs with heart
                                 failure                                                     ♦    Monitoring: wkly INR initially, then 6-8wkly once INR stabilizes.
    Digoxin                    ♦ Good for PT with heart      ♦ Digitalis toxicity            ♦    Adjustment of warfarin dose:
                                 failure                     ♦ Heart block                                  o    after change in drugs that interact with warfarin (eg amiodarone)
                               ♦ Caution in elderly and PT ♦ Bradycardia                                    o    surgery (stop warfarin for 5 days prior to surgery)
                                 with renal dysf(x)
    Amiodarone                 ♦ Good for PT with heart      ♦ Thyroid dysfunction
                                 failure                     ♦ Hepatotoxicity
                               ♦ Not first line due to SEs – ♦ Torsades de pointes
                                 require monitoring of LFT   ♦ Warfarin & digoxin
                                 and TFT                         interaction
           *combination therapies are possible eg digoxin & β-blockers
♦    Non-pharmacological rate control:
           Permanent pacing                                                                                                                                Digitally signed by DR WANA HLA SHWE
                                                                                                                                                           DN: cn=DR WANA HLA SHWE, c=MY,
           AV nodal ablation & permanent pacing:                                                                                                           o=UCSI University, School of Medicine, KT-
                                                                                                                                                           Campus, Terengganu, ou=Internal Medicine
                                                                                                                                                           Group, email=wunna.hlashwe@gmail.com
                                                                                                                                                           Reason: This document is for UCSI year 4
                                                                                                                                                           students.
Anticoagulation:                                                                                                                                           Date: 2009.02.24 10:15:03 +08'00'

♦    Prevent thromboembolic Cxs eg stroke & peripheral arterial thromboembolism
♦    Risk factors
       High risk factors     ♦    Prior stroke/ TIA/ systemic embolism
                             ♦    Prosthetic heart valve
                             ♦    Rheumatic mitral stenosis
                             ♦    >75YO
       Moderate risk factors ♦    60-75YO                 ♦     LVEF ≤35%
                             ♦    HPT                     ♦     DM
                             ♦    CCF                     ♦     Thyrotoxicosis
                             ♦    Coronary artery dz
       Low risk factors      ♦    <60YO

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Atrial fibrillation management summary

  • 1. Management of Atrial Fibrillation ♦ Assess the need to convert to sinus rhythm Causes of Atrial Fibrillation Physical Exam Cardiac ♦ Valvular dz – MR, MS ♦ Sick sinus syndrome ♦ confirm AF (4 signs) ♦ IHD ♦ Post-cardiac surgery o IR IR pulse ♦ HPT ♦ Peri-/myo-carditis o Single flicker JVP - absence of ‘a’ wave ♦ Post MI ♦ Pre-excitation syndrome o pulse deficit ♦ CCF ♦ Acute pul. Embolism o varying loudness of 1st heart sound ♦ ASD ♦ Lone AF (no known ♦ signs of underlying causes of AF– BP, goiter and signs of thyrotoxicosis, ♦ Cardiomyopathy etiology or structural heart auscultation for murmurs (MR/MS) dz. Dx of exclusion) ♦ complications – CCF, previous stroke Non-Cardiac ♦ Hyperthyroidism ♦ DM ♦ Sepsis esp pneumonia ♦ Alcohol Investigations ECG ♦ to document AF, any evidence of MI, LVH/LAH Morbidities of AF CXR ♦ chamber size, heart failure ♦ ↓ cardiac output – malaise and effort intolerance FBC ♦ aggravation of MI and heart failure U/E ♦ ↑ risk of Thromboembolism and stroke TFT ♦ hyperthyroidism Transthoracic ♦ structural HD (CMP, valvular dz, intracardiac shunt, pericardial Types of AF: echocardiogram HDz), ♦ 1st detected episode - may not need tx if episode is brief/ known reversible cause (TTE) ♦ chamber sizes ♦ Acute AF – detected within 24-48h, has high chance of pharm/electrical cardioversion ♦ LV size and function. ♦ Paroxysmal AF – AF lasting less than 7 days Additional Invxs ♦ Persistent AF – >7 days 24h Holter ♦ Quantify freq & duration of symptomatic & asymp. AF episodes ♦ Permanent AF – previous attempts to restore sinus rhythm have failed/ AF lasted >1y. ♦ Look for sinus node dysf(x) or sick sinus syndrome The probability of successful cardioversion is very low ♦ Assess adequacy of rhythm or rate control ♦ Assess time of onset of AF (eg night in vagally-mediated AF) Clinical Presentations ♦ Identify PTs with frequent atrial ectopics & nonsustained atrial ♦ Palpitations tachycardia suitable for catheter ablation ♦ CP Transesophageal ♦ Gives better visualization of LA thrombus cf TTE) ♦ Dyspnoea echocardiogram ♦ Use before elective cardioversion in PTs w/o prior 3wks ♦ Fatigue (TEE) warfarin ♦ Light headedness Exercise stress test ♦ Assess PT with AF ppted by exertion, IHD or MI ♦ Syncope ♦ Routinely done for PTs ≥40YO or with significant coronary risk ♦ Cxs of AF – heart failure, haemodynamic impairments, stroke factors. ♦ Asymptomatic (25%) Electrophysiological ♦ For PTs w hx of syncope to exclude sick sinus syndrome and study (EPS) Wolff-Parkinson-White syndrome Evaluation of AF ♦ stable or unstable Management of AF: ♦ confirm diagnosis of AF with 12 lead ECG ♦ Aims: • Improve symptoms ♦ classify type of AF o Control ventricular rate • Reduce TE stroke risk ♦ determine underlying cause/factors contributing to AF (eg structural and ischaemic o Reestablish sinus rhythm • Prevent cardiac remodeling HDz, estimating LVEF, valvular HDz, CMP, HPT) o Anticoagulate to prevent Thromboembolism and hence HFailure & CMP ♦ look for complications of AF ♦ determine risk of future complications, i.e. stroke, from AF Unstable: o HTN/ old age/ IHD/ heart failure / previous stroke/ DM o immediate sync. Cardioversion ♦ Assess adequacy of control of ventricular rate during AF o f/u with anticoagulation therapy for 4 weeks
  • 2. Stable: a) Acute AF (<48h) ♦ Can be cardioverted (pharm/electrical) without prior long-term anticoagulation Rhythm Control: ♦ Give IV heparin before proceeding ♦ Spontaneous cardioversion occurs in 50-70% of PTs w/in 24 to 48 hrs, but unlikely to ♦ And switch to oral, maintain INR at 2-3 for 4 weeks whatever the outcome occur if AF persisted for > a week. Drug/electrical cardioversion will be necessary. ♦ Success rate of cardioversion decrease as duration of AF increase, therefore perform b) Persistent/ Recurrent Paroxysmal AF early If minimal symptoms, ♦ Problems: failure in maintenance of sinus rhythm in >50% of PTs, significant SE of 1) Rate control drugs used o Beta-blocker o Ca blockers e.g. diltiazem/ verapamil ♦ Pharmacological Cardioversion: o Digoxin (esp if concurrent HF) Drug Comments SE o Sotalol Class IC arrhythmics ♦ Contraindications ♦ conversion to atrial flutter 2) Assess for risk of thromboembolism and anticoagulate as necessary (propafenone 300- - IHD ♦ ventricular tachycardia This is the recommended management for most patients, unless acute onset (<48h), or 600mg PO stat, - CCF ♦ enhanced AV nodal symptomatic, or complicated flecainide150-200mg - Lt vent dysf(x) conduction PO stat) - major conduction ♦ CCF disturbances c) Symptoms/ complications (e.g. syncope, heart failure, stroke) Amiodarone ♦ Takes days to wks for onset ♦ Hepatotoxic ♦ Rate control initially followed by cardioversion, with anticoagulation (600-800mg/day PO) ♦ Safe for PT with structural heart ♦ Thyroid dysfunction ♦ Then, o anticoagulate for 3 weeks with warfarin (keep INR 2-3) before cardioversion dz or heart failure ♦ GI upset ♦ Monitor LFT & TFT 6 mthly for SE ♦ Bradycardia ♦ Amiodarone ♦ Flecainide ♦ Torsades de pointes ♦ Propafenone ♦ polyneuropathy o Alternatively, do TEE to look for LA thrombus. If none, give IV Heparin and Dofetilide & ibutilide ♦ perform DC cardioversion w/o prior anticoagulation. Quinidine ♦ Hypotension ♦ Post cardioversion, maintain INR at 2-3 for 4 weeks ♦ Torsades de pointes ♦ Maintenance of sinus rhythm (Flecainide, propafenone, sotalol, amiodarone) Sotalol ♦ NOT for cardioversion ♦ Torsades de pointes ♦ Only for maintaining sinus rhythm ♦ CCF AF ♦ Exacerbation of COPD ♦ Electrical cardioversion: Unstable Stable o PT must be fasted and sedated, with good IV access and airway Mx o Check electrolyte and anticoagulation status ♦ Sync cardioversion Monophasic AF 200 joules, increments up to 360 joules ♦ 4 wks anticoagulation Atrial flutter 50 joules Biphasic AF 100 joules initially o Cxs: Thromboembolism, arrhythmia, myocardial injury, heart failure, skin burns. st 1 episode / Acute AF (<48hrs) Persistant / recurrent paroxysmal AF ♦ Other non-pharmacological rate control therapies ♦ Pharm / electrical cardioversion w/o prior anticoagulation o Permanent Pacing ♦ 4 wks anticoagulation o Catheter ablation – for PTs with paroxysmal AF due to atrial ectopics, PT with ♦ long-term anticoagulation not necessary SVT or atrial flutter o Surgical ablation – “Maze” procedure: consider concomitant Sx ablation in PTs going for open heart Sx for valvular, ischaemic or congenital heart dz. Asymptomatic Symptomatic / complicated ♦ Maintenance of Sinus Rhythm ♦ Rate control ♦ Rate control & anticoagulation o Flecainide, propafenone and sotalol are first line drugs ♦ Long-term anticoagulation ♦ Cardioversion & maintain sinus rhythm o Amiodarone superior to previous drugs, but last choice of drug due to long term ♦ Long term anticoagulation extracardiac SE. • Treat ppt factor if present • Failure of drug therapy to achieve rate control or maintain sinus rhythm – consider pacemakers, defibrillator or catheter ablation
  • 3. o Choice of drug in heart dz: Heart failure: use amiodarone ♦ Contraindications to anticoagulation CAD: use sotalol ♦ Significant bleeding or fall risk ♦ PT unlikely to comply with diet & HPT with LVH ≥1.4cm: use amiodarone ♦ Recent surgery / trauma monitoring regimen ♦ Thrombocytopenia ♦ Active peptic ulcer dz Rate Control: ♦ Similar efficacy to rhythm control, but drugs used are safer and there is no problems ♦ Antithrombotic strategies wrt maintenance of sinus rhythm Any high-risk factors present Long-term oral anticoagulation (target INR2.5; ♦ Pharmacological rate control: >60YO with one other range 2.0-3.0) Drug Comments SE moderate risk factor β-blockers ♦ First line Rx ♦ Bronchoconstriction. CI in <60YO + one moderate risk Either aspirin 100mg/day or warfarin depending on (propranolol, atenolol, ♦ Caution in PTs with heart asthma factor PT preference, risk of blding and access to sotalol) failure ♦ Heart failure 60-75YO with no risk factor anticoagulation monitoring ♦ Hypotension Male >75 with no risk factor ♦ Heart block Low risk or warfarin is CI Aspirin (100-300mg/day). Alternatives: ticlopidine, ♦ Bradycardia clopidogrel, dipyridamole CCB (verapamil, ♦ IV CCB useful in ♦ Hypotension <60YO with no risk factors & Long term aspirin or no Rx diltiazem) emergencies ♦ Heart block normal left atrial size ♦ Preferred over β-blockers ♦ Heart failure *always consider PT factors in determining target INR level (eg fall risk in elderly, recurrent in PT with COPD TE events despite anticoagulation, prosthetic heart valves) & modify Rx accordingly ♦ Caution in PTs with heart failure ♦ Monitoring: wkly INR initially, then 6-8wkly once INR stabilizes. Digoxin ♦ Good for PT with heart ♦ Digitalis toxicity ♦ Adjustment of warfarin dose: failure ♦ Heart block o after change in drugs that interact with warfarin (eg amiodarone) ♦ Caution in elderly and PT ♦ Bradycardia o surgery (stop warfarin for 5 days prior to surgery) with renal dysf(x) Amiodarone ♦ Good for PT with heart ♦ Thyroid dysfunction failure ♦ Hepatotoxicity ♦ Not first line due to SEs – ♦ Torsades de pointes require monitoring of LFT ♦ Warfarin & digoxin and TFT interaction *combination therapies are possible eg digoxin & β-blockers ♦ Non-pharmacological rate control: Permanent pacing Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, AV nodal ablation & permanent pacing: o=UCSI University, School of Medicine, KT- Campus, Terengganu, ou=Internal Medicine Group, email=wunna.hlashwe@gmail.com Reason: This document is for UCSI year 4 students. Anticoagulation: Date: 2009.02.24 10:15:03 +08'00' ♦ Prevent thromboembolic Cxs eg stroke & peripheral arterial thromboembolism ♦ Risk factors High risk factors ♦ Prior stroke/ TIA/ systemic embolism ♦ Prosthetic heart valve ♦ Rheumatic mitral stenosis ♦ >75YO Moderate risk factors ♦ 60-75YO ♦ LVEF ≤35% ♦ HPT ♦ DM ♦ CCF ♦ Thyrotoxicosis ♦ Coronary artery dz Low risk factors ♦ <60YO