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Atrial Fibrillation – Information for GPs

Background

NHS Scarborough and Ryedale CCG (SRCCG) commissions healthcare on behalf of its local population across primary, secondary and tertiary care sectors. Commissioning policy including clinical referral pathways and thresholds have been developed and defined using appropriate NICE guidance and other peer reviewed evidence and are summarised here in order to guide and inform referrers.

This commissioning policy is needed in order to clarify the criteria for referral for Atrial Fibrillation.

Definition

Definition 2016 ESC Guideline for the Management of Atrial Fibrillation

Patient has evidence of AF on a rhythm strip or 12 lead ECG with absence of p waves and absolutely irregular RR intervals, lasting at least 30s.

General points

It is expected that the majority of people with AF will be managed in the community and do not require cardiology referral.

  • Atrial fibrillation is extremely common in the elderly population affecting 10% of the over 80s
  • At least 30% of cases are asymptomatic, this is more frequent in the elderly where AF can present with stroke in these higher risk individuals
  • AF is usually associated with other cardiovascular conditions, IHD, hypertension and less commonly valvular heart disease
  • It can also be associated with pulmonary disease, thyroid disorders and alcohol intake, and acutely with sepsis especially pneumonia: pulmonary embolism and cardiac surgery.

Exclude the following Red Flag Symptoms and Signs where the Clinician should consider URGENT Hospital Advice or Admission

  • Severe SOB and AF (see heart failure pathway)
  • Chest Pain and AF with a rapid ventricular rate
  • Syncope with AF (please advise not to drive)
  • Wolff Parkinson White Syndrome and AF

Management

Recommended for all patients with AF:

  • 12 lead ECG to confirm the diagnosis and identify other cardiac problems
  • Blood tests:- FBC, U & Es, TFTs, LFTs,
  • An assessment of thromboembolic risk using CHADSVASc and of bleeding risk using HASBLED
  • If ventricular rate is > 100 the patient should be started on a beta blocker(atenolol 25mg or bisoprolol 2.5mg) or rate limiting calcium channel blocker (diltiazem starting 120mg/d). if a beta blocker is contraindicated. Diltiazem modified release preparations must be prescribed by brand name once daily
  • either AdixemXL or Tildiem LA.
  • Digoxin should be reserved for second line use.
  • People with a CHADSVASc score of 2 or more should be counselled about their thromboembolic risk and the benefits of anticoagulation. When agreed they should be commenced on appropriate anticoagulation
  • Counsel the patient about the risks and benefits and initiate therapy if appropriate or refer to an appropriate clinic. The dontwaittoanticoagulate.com and sparctool.com websites can be used to demonstrate risks and benefits.
  • People with a CHADSVASc score of 1 should also be made aware of their risk of stroke and of the balance between risk of bleeding with anticoagulation and stroke risk reduction. They may wish to opt for anticoagulation.
  • CHADSVASc score of 1 in a woman related to gender alone is not an indication for
  • The NOAC (Novel Oral Anticoagulants/ DOAC (Direct Oral Anticoagulants) are NOT indicated for valvular AF with significant mitral stenosis or metallic valve replacement

NICE guidelines state that there is no role for aspirin or other antiplatelet therapy to prevent thromboembolic stroke in AF. The risk of bleeding rises with combination of antiplatelet and anticoagulant therapy. The need for antiplatelet therapy in combination should be assessed on initiation of therapy and at medication review. Indications to request a consultant opinion

  • Recent (< 3 months) onset of symptomatic AF where cardioversion may be considered
  • AF with poor ventricular rate control (> 100) despite maximally tolerated doses of a betablocker or diltiazem. Where possible, poor rate control should be confirmed by 24hr ECG before referral.
  • AF which has followed an acute event
  • AF in a young person with no obvious cause
  • Atrial Flutter
  • Symptomatice paroxysmal AF

Rhythm control should only be initiated in secondary care

  • Consider pharmacological and or electrical treatment for rhythm control for people with arial fibrillation whose symptoms continue after heart rate has been controlled or for whom a rate-control strategy has not been successful
  • Pharmacological rhythm control may include amiodarone, betablockers and dronedarone (dronedarone is amber shared care)

Additional Indications for Echocardiogram

  • AF in a person with a murmur suggestive of a structural problem where a NOAC/DOAC may be contraindicated
  • AF in person <65

Information to include in referral letter

  • Please clearly indicate the indication for which you are referring the patient
  • Please include the CHADSVASC and HASBLED scores
  • Please include the values of the investigations prior to referral: ECG, FBC, U& E, TFT, LFT,
  • Please attach ECG evidence of AF
  • Please do not wait until after a clinic visit before offering anticoagulation. Counsel the patient about the risks and benefits and initiate therapy if appropriate. See sparctool.com and dontwaittoanticoagulate.com

Other important points

  • Patients with AF and symptoms and signs of Heart Failure should be referred via the Heart Failure Pathway
  • All people with AF (paroxysmal, persistent and permanent) and atrial flutter should be assessed and managed for thromboembolic risk in the same way
  • Where the ECG diagnosis is not clear a 48 hour reporting service is available via the Cardiorespiratory Department at Scarborough and York Hospitals
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