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Atrial Fibrillation Glos Care Pathway Overview

This Atrial Fibrillation (AF) pathway has been developed to aid Health Care Professionals in the detection and management of atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, which if left untreated can lead to stroke, heart failure and other comorbidities. It is more common in men than women and the prevalence increases with age. Atrial fibrillation occurs when chaotic electrical activity develops in the atria and takes over from the sinus node so that the atria no longer beats in an organised way and as a consequence the heart pumps less efficiently.

Other conditions or diseases can also increase chances of atrial fibrillation:

Please click the relevant flowchart box to be taken directly to textual information

                                   

Red Flags
Admit for urgent assessment and intervention, if the patient has atrial fibrillation associated with any of the following:
  • Rapid pulse (greater than 150 beats per minute) and/or low blood pressure (systolic blood pressure less than 100mmHg)
  • Loss of consciousness, severe dizziness, ongoing chest pain or increasing breathlessness
  • A complication of atrial fibrillation (stroke, transient ischaemic attack or acute heart failure)
Presentation

An irregular pulse could be a sign of atrial fibrillation; however some people only have mild symptoms, while others have no symptoms at all.

  1. Paroxysmal AF – recurrent episodes of AF that terminate spontaneously within seven days without treatment
  2. Persistent AF – episodes lasting longer than seven days, or less than seven days when treated
  3. Permanent AF – when the presence of AF is accepted by the patient and the clinician and strategies to restore sinus rhythm are not being pursued.

Certain situations can trigger atrial fibrillation:

Differential Diagnosis
  • Atrial flutter
  • Atrial extrasystoles
  • Supraventricular tachyarrhythmias
  • Atrioventricular nodal re-entrant tachycardia
  • Ventricular tachycardia
Initial Primary Care Assessment

  • Atrial fibrillation can be detected by feeling the pulse on the patients’ wrist. If they are in atrial fibrillation, their pulse will feel irregular and beats may vary in strength. You might also feel this pattern if they have missed beats or extra beats (ectopic). These are very common and usually nothing to worry about. AliveCor can be used at this point to help clarify or exclude the diagnosis.
  • Perform a 12 lead electrocardiogram (ECG) in patients whether symptomatic or not where atrial fibrillation is suspected because an irregular pulse has been detected even if this has been confirmed with an AliveCor
  • In patients with suspected paroxysmal atrial fibrillation undetected by standard ECG recording:
    • Use a 24 hour ambulatory ECG monitor in those with suspected asymptomatic episodes or symptomatic episodes less than 24 hours apart
    • Use an event recorder ECG or Alivecor device in those with symptomatic episodes more than 24 hours apart.

Assessment of stroke risk

Use the CHA2DS2-VASc risk score to assess stroke risk in people with any of the following:

  • Symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
  • Atrial flutter

Assessment of bleeding risk

Use the HAS-BLED score to assess and modify the risk of bleeding in people who are starting or have started anticoagulation. Modifiable risk factors include:

  • Uncontrolled hypertension
  • Poor control of international normalised ratio (INR)
  • Concurrent medication, for example concomitant use of aspirin or non-steroidal anti-inflammatory drug (NSAID)
  • Harmful alcohol consumption

Interventions to prevent stroke in patients with atrial fibrillation

Anticoagulation

Anticoagulation may be with warfarin or other vitamin K antagonist.rivaroxaban, apixaban, dabigatran etexilate, edoxaban.

  • Consider anticoagulation for men with a  CHA2DS2-VASc score of 1. Bleeding risk must also be taken into account
  • Offer anticoagulation to people with  CHA2DS2-VASc score of 2 or above. Bleeding risk must also be taken into account

Men with a CHA2DS2-VASc score of 0 or women with a score of 1 based on gender alone should not be offered anticoagulation.

The gender risk factor of being a woman only comes into play if you have another CHA2DS2-VASc risk factor.

DOAC’s have been shown to be as effective as warfarin and there is no robust evidence for using one DOAC over another. However, it is very important that DOACs, are taken regularly, in the correct dose and in the correct way e.g. rivaroxaban must be taken with food.

Compliance tends to be higher with once daily regimens. Please follow this link for decision support for prescribing DOAC’s..

Please see the Prescribing section for further information.

Rate and rhythm control

Rate control

  • Offer beta-blockers as the first line therapy. Consider a rate-limiting calcium-channel blocker if beta-blockers are contraindicated or causing side effects
  • Consider digoxin monotherapy for patients with non-paroxysmal atrial fibrillation only if they are sedentary
  • If monotherapy with either beta-blockers or rate limiting calcium channel blockers does not control symptoms then consider adding digoxin. If rate control is not achieved then seek specialist guidance on further management
  • Beta-blockers and rate limiting calcium channel blockers in combination should be used with caution and ideally only following discussion with a cardiology specialist.

Do not initiate amiodarone in primary care.

Offer rate control as the first-line strategy to all patients with atrial fibrillation, except in the following patients who should be considered for rhythm control and referred for specialist opinion:

Rhythm Control

The following should be considered for rhythm control and referred for specialist opinion

  • Patients with atrial fibrillation who are symptomatic despite treatment (including patients with significant tachycardia/bradycardia)
  • Any patients with clinical evidence of heart failure or patients with known heart failure who develops atrial fibrillation. It may be appropriate to refer these patients to the local Heart Failure Service.
  • Any patient with syncope or alteration of level of consciousness (note – need to consider DVLA rules on referral)
  • Any patient with atrial flutter/atrial tachycardia
  • Patients with complex implantable cardiac devices e.g. CRT or ICD.
  • Patients with known congenital heart disease or cardiomyopathy or known significant valve disease. If in any doubt please use Advice & Guidance.
  • Whose atrial fibrillation has a reversible cause (e.g. thyrotoxicosis, sleep disordered breathing)
  • Wolff-Parkinson-White syndrome or a prolonged QT interval is suspected or confirmed on the ECG
  • Symptomatic paroxysmal atrial fibrillation despite rate limiting therapy
  • Suspected paroxysmal atrial fibrillation
  • The patient is less than 50 years of age
  • There is uncertainty regarding whether rate or rhythm control should be used - Please consider Advice and Guidance.

Patients in whom a rhythm control strategy may be appropriate should be referred for a cardiology specialist opinion where the following options may be considered:

  • Cardioversion
  • Left atrial ablation
    If drug treatment has failed to control symptoms of atrial fibrillation or is unsuitable:
    - Offer left atrial catheter ablation to people with paroxysmal atrial fibrillation
    - Consider left atrial catheter or surgical ablation for people with persistent symptomatic atrial fibrillation with a duration of less than a year
  • Pacing with AV node ablation
    Consider pacing and atrioventricular node ablation for people with permanent atrial fibrillation with symptoms or left ventricular dysfunction thought to be caused by high ventricular rates.

Ensure that the package of care covers:

  • Stroke awareness and measures to prevent stroke
  • Rate control
  • Assessment of symptoms for rhythm control
  • Who to contact for advice if required
  • Psychological support if needed
  • Up-to-date education and information:
    • Cause, effects and possible complications of atrial fibrillation
    • Management of rate and rhythm control
    • Anticoagulation
    • Support groups/networks (please see Patient and Carer Information section)
When to Refer

Refer Red Flags immediately.

See rhythm control section above for those who should be considered for referral for specialist opinion.

Refer patients promptly at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed.

An ECG must be attached to the referral.

Please ensure that co-morbidities such as hypertension and obesity are being managed at the same time as referral.

Services

Cardiology – GHNHSFT

GHNHSFT team of specialist cardiologists provide a full range of cardiac (heart) care for patients in the treatment and prevention of heart conditions.
Please see Cardiovascular: general and other page for Cardiology contact details including the ‘Hot Advice Line’ and referral information.
 

Healthy Lifestyle Service

Healthy Lifestyles Gloucestershire is an integrated service which provides people with lifestyle support through one single point of access for:

  • Smoking cessation
  • Weight management
  • Alcohol reduction
  • Physical activity support

Healthy Lifestyle Coaches don’t write diet plans or exercise programmes, instead it works with patients to collaboratively identify small changes that can be made in lifestyle and provides motivational support to achieve their lifestyle goals.

Please click here for further information and referral details.
 

Alcohol and Drug Services

Please see Substance Misuse pages for further information and referral details.

Ongoing Primary Care Management

For patients who are not taking an anticoagulant, review stroke risk when they reach 65 years of age or if they develop any of the following at any age:

For people who are not taking an anticoagulant due to bleeding risk or other factors, review stroke and bleeding risks annually.

For people who are taking an anticoagulant, review the need for and quality of anticoagulation at least annually or more frequently if indicated.

When reassessing anticoagulation, take into account the following factors:

  • Cognitive function
  • Adherence to prescribed therapy
  • Illness
  • Interacting drug therapy
  • Lifestyles factors (i.e. diet, alcohol consumption)

All drivers are required by law to report any condition that may affect their ability to drive to the DVLA. Failure to do so can result in a £1,000 fine, invalidate their insurance and lead to possible prosecution if the person is involved in an accident. GP's have a vital role to play in ensuring that patients adhere to these rules.

If you have any reason at all to suspect that the injury will affect a patient's ability to drive you should tell them this and provide the number for the DVLA Drivers Medical Group.

Atrial fibrillation does have implications for a Group 2 licence.

Further information can be found on the DVLA website: https://www.gov.uk/driving-medical-conditions.

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