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Atrial Fibrillation in Lusaka – Pathoaetiology, Pathophysiology and Clinical Management Challenges in Primary Care Settings
Abstract
Background: Atrial Fibrillation (AF) is the commonest sustained arrhythmia the world over and is associated with substantial morbidity and mortality. An excessive ventricular rate, a loss of atrial contraction and an irregular ventricular filling time are the hallmark of this condition and all have negative clinical consequences. AF can lead to HF and AF is reported in 10-50% of patients with HF. Presence of AF in HF is an independent risk factor for death. However, the prevalence of AF and its associated risk factors and/or complications in Zambia have not been elucidated. Modalities of investigations and treatment protocols for rate and rhythm control in AF remain unexplored. Although individuals with AF are at risk of death from multiple cardiovascular causes, stroke is the most feared of them all. However, it is not known how often or effectively oral anticoagulation is used in Zambia.
Methodology: A prospective, clinical registry captured data on patients presenting to UTH medical admission ward with an electrocardiographic (ECG) diagnosis of Atrial Fibrillation/Flutter. It captured the prevalence of emerging AF/flutter risk factors and co-morbidities and documented the way AF/flutter patients are managed, and the frequency of interventions. Consecutive patients, with documented AF (as their primary or secondary diagnosis) were identified for possible enrollment.
Results: In a period of just over 6 months, a total of 36 patients of AF were enrolled (15 male (42%)and 21 female(58%). They were all classified as patients with either permanent (91.7%) or persistent AF (8.3%). No candidates with paroxysmal AF were captured in this database. The ages ranged from 16 – 90 years. Predominant cardiac diagnoses included a) Valvular heart disease 26 (72.2%), b) Heart failure 22(61%) and C) Hypertensive Heart Disease 12(33%). Co-morbidities included previous stroke or transient ischemic attacks(TIAs) 8 (22.2%), dementia 1(2.8%), pericarditis 2(5.6%), emphysema 1(2.8%), diabetes mellitus 2(5.6%) and hyperthyroidism 1(2.8%). On presentation to the UTH the drugs the candidates were on included 1)Rate control medication (beta-blocker 2.8%, CCB (8.3%), Digoxin (66%) & Amiodarone (2.8%)), 2) Rhythm control medication (Amiodarone (2.8%),3) Anticoagulants (Warfarin (6.9%) and 4) anti-platelets (Aspirin 42.9%). Only pharmacological cardioversion was attempted in 5.6% patients. None were defibrillated.
Conclusions: AF is a common arrhythmia in primary care settings in Lusaka. A proportion of patients with symptoms of AF go undiagnosed due to a lack of ambulatory rhythm monitoring devices. Rheumatic Heart Disease, hypertensive heart disease and heart failure are major risk factor for AF. Treatment of AF is far from optimization as evidenced by the large proportion of patients not prescribed either rate control or rhythm control medication. The use of oral anticoagulation is also very low as is also the use of monitoring facilities for the International Normalised Ratio (INR) measurements.
Methodology: A prospective, clinical registry captured data on patients presenting to UTH medical admission ward with an electrocardiographic (ECG) diagnosis of Atrial Fibrillation/Flutter. It captured the prevalence of emerging AF/flutter risk factors and co-morbidities and documented the way AF/flutter patients are managed, and the frequency of interventions. Consecutive patients, with documented AF (as their primary or secondary diagnosis) were identified for possible enrollment.
Results: In a period of just over 6 months, a total of 36 patients of AF were enrolled (15 male (42%)and 21 female(58%). They were all classified as patients with either permanent (91.7%) or persistent AF (8.3%). No candidates with paroxysmal AF were captured in this database. The ages ranged from 16 – 90 years. Predominant cardiac diagnoses included a) Valvular heart disease 26 (72.2%), b) Heart failure 22(61%) and C) Hypertensive Heart Disease 12(33%). Co-morbidities included previous stroke or transient ischemic attacks(TIAs) 8 (22.2%), dementia 1(2.8%), pericarditis 2(5.6%), emphysema 1(2.8%), diabetes mellitus 2(5.6%) and hyperthyroidism 1(2.8%). On presentation to the UTH the drugs the candidates were on included 1)Rate control medication (beta-blocker 2.8%, CCB (8.3%), Digoxin (66%) & Amiodarone (2.8%)), 2) Rhythm control medication (Amiodarone (2.8%),3) Anticoagulants (Warfarin (6.9%) and 4) anti-platelets (Aspirin 42.9%). Only pharmacological cardioversion was attempted in 5.6% patients. None were defibrillated.
Conclusions: AF is a common arrhythmia in primary care settings in Lusaka. A proportion of patients with symptoms of AF go undiagnosed due to a lack of ambulatory rhythm monitoring devices. Rheumatic Heart Disease, hypertensive heart disease and heart failure are major risk factor for AF. Treatment of AF is far from optimization as evidenced by the large proportion of patients not prescribed either rate control or rhythm control medication. The use of oral anticoagulation is also very low as is also the use of monitoring facilities for the International Normalised Ratio (INR) measurements.
