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WELSH GUIDELINES - All Wales clinical pathway for Atrial Fibrillation (AF)

All Wales clinical pathway for Atrial Fibrillation (AF)

Diagnosis and management

           Primary care                 Secondary care            Primary and secondary care

New onset Atrial Fibrillation/Atrial Flutter with symptoms Targeted AF case finding (eg chronic <48 hours or haemodynamically unstable. disease clinic) or clinical suspicion of AF

 Acute Medical Referral Recommended.

ECG inconclusive – AF still suspected (paroxysmal) Organise ECG monitoring for long enough to capture suspected episodes

Use a 24-hour ambulatory ECG monitor in those with

ECG in those with symptomatic episodes more than 24 hours apart. Consider use of a commercial ambulatory ECG event-recording device such as AliveCor®

AF confirmed

Perform an Echo

Type of Atrial Fibrillation

Permanent – Accepted and longstanding.

Persistent – Lasting >7 days, unlikely to revert to Sinus Rhythm spontaneously. Paroxysmal – Recurrent episodes lasting <48 hours, maximum 7 days.

AF confirmed

Assess risk of Stroke using CHA2DS2-VASC score (see overleaf) and initiate anticoagulation as appropriate:

Perform routine investigations

• TFT, FBC, U&E, glucose, chest x-ray, manual blood pressure

Wales Cardiac Network, Dr Richard Cowell, 04.12.18. To be reviewed August 2020.

Risk Factor ( CHA2DS2-VASC)

Score

Congestive heart failure/LV dysfunction

1

Hypertension

1

Age ≥ 75 years

2

Diabetes mellitus

1

Stroke/TIA/thrombo-embolism

2

Vascular disease

1

Age 65-74 years

1

Sex category (i.e. female sex)

1

Maximum score

9

Primary Care Management:

General measures: Blood pressure  control and weight optimisation.

Prescribe beta-blocker as first line e.g. Bisoprolol 1.2510mg daily if rate control is needed.

If beta-blocker contraindicated and LV function is normal, prescribe rate-limiting calcium channel blocker: Diltiazem or Verapamil. Only consider Digoxin as monotherapy if patient is predominantly sedentary.

If beta-blocker contraindicated and there is LV dysfunction, prescribe Digoxin as first line.

HASBLED SCORE

 

Letter

Clinical Characteristic

Pts awarded

H

Hypertension

1

A

Abnormal renal and liver function (1pt each)

1 or 2

S

Stroke

1

B

Bleeding

1

L

Labile INRs

1

E

Elderly (e.g. age > 65 years)

1

D

Drugs or alcohol (1 point each)

1 or 2

 

Maximum 9 pts

Amiodarone, Dronedarone, Sotolol and Flecainide should only be initiated by a Cardiologist. Monitor Apical HR and BP. If resting ventricular rate is ≥110 or is symptomatic consider increasing dose of beta-blocker, calcium channel blocker or add digoxin.

CHA2DS2-VASC score

Adjusted stroke rate (%/y)

0

0%

1

1.3%

2

2.2%

3

3.2%

4

4.0%

5

6.7%

6

9.8%

7

9.6%

8

6.7%

9

15.2%

Patients who should be referred for out patient specialist assessment

Notes re: anticoagulation

Patients with mitral stenosis, mechanical prosthetic heart valves or significant renal impairment should be treated with warfarin.

Adjusted-dose Warfarin (target INR 2.5, range 2.0 to 3.0) reduces relative stroke risk by 60%.

Use HASBLED Score (above) to determine bleeding risk and to identify modifiable risk factors- in itself not a tool to determine whether patients should be anticoagulated or not.

The latest European Society of Cardiology Guidelines suggest that the Direct Oral Anticoagulants- Apixaban, Dabigatran, Edoxaban and Rivaraxaban should be considered first line therapy in patients with AF as opposed to Warfarin (see local guidelines).

Where Warfarin control is poor and INR time in therapeutic range <60% over a period of 6 months (excluding first 1-3 months after initiation having checked compliance), consider a new oral anticoagulant (Apixaban, Dabigatran, Edoxaban or Rivaroxaban). These new drugs require dose reduction or cessation when creatinine clearance is significantly reduced using the Cockcroft Gault formula. Do not use eGFR to determine renal function.

This All Wales Clinical Pathway for AF has been devised with reference to the following AF Guidelines on Anticoagulation: