Arrhythmia

 

Atrial fibrillation is the most common sustained cardiac arrhythmia, and estimates suggest its prevalence is increasing.  If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities.  Men are more commonly affected than women and the prevalence increases with age

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Diagnosis and assessment

Perform manual pulse palpation to assess for the presence of an irregular pulse that may indicate underlying atrial fibrillation in people presenting with any of the following:

  • breathlessness/dyspnea
  • palpitations
  • syncope/dizziness
  • chest discomfort
  • stroke/transient ischaemic attack

Perform an electrocardiogram (ECG) in all people, whether symptomatic or not, in whom atrial fibrillation is suspected because an irregular pulse has been detected

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Personalised package of care and information

Offer people with atrial fibrillation a personalised package of care. Ensure that the package of care is documented and delivered, and that it covers:

  • stroke awareness and measures to prevent stroke
  • rate control
  • assessment of symptoms for rhythm control
  • who to contact for advice if needed
  • up-to-date and comprehensive education and information on:
    • cause, effects and possible complications of atrial fibrillation
    • management of rate and rhythm control
    • anticoagulation
    • practical advice on anticoagulation
    • support networks (e.g. cardiovascular charities)

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Referral for specialist management

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

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Assessment of stroke and bleeding risks

Stroke risk

  • Use the CHA2DS2-VASc Stroke risk score in people with any of the following:
    • symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
    • atrial flutter
    • a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm

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Bleeding risk

  • Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation. Offer modification and monitoring of the following risk factors:
    • uncontrolled hypertension
    • poor control of international normalised ratio (INR) ('labile INRs')
    • concurrent medication, for example concomitant use of aspirin or a non-steroidal
    • anti-inflammatory drug (NSAID)
    • harmful alcohol consumption

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Stroke Prevention in Atrial Fibrillation Risk Tool

  • Alternatively, you can use the interactive Stroke Prevention in Atrial Fibrillation Risk (SPARC) Tool to assess the risk of stroke in patients with atrial fibrillation, as well as the risk of major bleeding.  Click here for the tool

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Interventions to prevent stroke

Anticoagulation

  • Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist

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Assessing anticoagulation control with vitamin K antagonists

  • Calculate the person's time in therapeutic range (TTR) at each visit. When calculating TTR:
    • use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing
    • exclude measurements taken during the first 6 weeks of treatment
    • calculate TTR over a maintenance period of at least 6months

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Antiplatelets

  • Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation

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Click here for the EKPG AF anticoagulation decision making tool for the prevention of stroke and systemic embolism in adults

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Rate and rhythm control

When to offer rate or rhythm control

  • Offer rate control as the first-line strategy to people with atrial fibrillation, except in people:
    • whose atrial fibrillation has a reversible cause
    • who have heart failure thought to be primarily caused by atrial fibrillation
    • with new-onset atrial fibrillation
    • with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
    • for whom a rhythm control strategy would be more suitable based on clinical judgment

Left atrial ablation and a pace and ablate strategy

  • 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 atrial fibrillation
    • discuss the risks and benefits with the person

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Primary Care AF Pathway

CHA2DS2-VASc Stoke Risk Score

Please use the CHA2DS2-VASc Stroke risk score to estimate the risk of stroke in patients with atrial fibrillation (AF).  This score is used to determine whether or not treatment is required with anticoagulation or antiplatelet therapy

HAS-BLED Score

Please use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation

Stroke Prevention in Atrial Fibrillation Risk Tool

Alternatively, you can use the interactive Stroke Prevention in Atrial Fibrillation Risk (SPARC) Tool to assess the risk of stroke in patients with atrial fibrillation, as well as the risk of major bleeding.  Click here for the tool

Electrocardiogram

An electrocardiogram (ECG) can usually be undertaken in primary care.  If your practice does not offer ECGs, please request an ECG from East Kent Hospitals

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

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