Atrial fibrillation

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Atrial fibrillation
June 2006
2
Changing clinical practice

• NICE guidelines are based on the best available
  evidence
• The Department of Health asks NHS organisations
  to work towards implementing guidelines
• Compliance will be monitored by the Healthcare
  Commission

3
Atrial fibrillation

• Atrial fibrillation (AF) is an atrial
  tachyarrhythmia characterised by predominantly
  uncoordinated atrial activation with consequent
  deterioration of atrial mechanical function
• On the ECG, there is an absence of consistent P
  waves instead there are rapid oscillations or
  fibrillatory waves that vary in size, shape and
  timing

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Reproduced by kind permission of Ashford and St.
Peters Hospitals NHS Trust
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Several causes of AF

• Often caused by co-existing medical conditions
  both cardiac and non-cardiac
• Associated with increasing age, hypertension,
  heart failure, diabetes mellitus and valve
  disease
• Dietary and lifestyle factors have also been
  associated with AF
• Common after surgery, especially cardiothoracic
  operations

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Classification of AF
Terminology Clinical features Pattern
Initial event (first detected episode) Symptomatic Asymptomatic Onset unknown May or may nor reoccur
Paroxysmal Spontaneous termination lt7 days and most often lt48 hours Recurrent
Persistent Not self-terminating Lasting gt7 days or prior cardioversion Recurrent
Permanent (accepted) Not terminated Terminated but relapsed No cardioversion attempt Established
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Need for this guideline

• AF is a significant risk factor for mortality, as
  well as stroke and other morbidities
• AF is the commonest sustained cardiac arrhythmia
• Too often, AF is detected only after the patient
  presents with serious complications of AF
• AF incidence and prevalence increase with
  increasing age. With an increasingly elderly
  population, AF is likely to become more common

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Commonest cardiac arrhythmia

• The prevalence of AF roughly doubles with each
  decade of age from 0.5 at age 5059 years to
  almost 9.0 at age 8090 years
• Present in 36 of acute hospital admissions
• Prevalence of 4.7 of people aged 65 years or
  over in general practice

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Prevalence of AF in the Renfrew-Paisley study
Cohort of men and women aged 4564 years (n
15,406)
Reproduced with permission of the BMJ Publishing
Group from Stewart S et al, Heart 2001 86516-21
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What needs to happen

• Opportunistic/targeted case detection including
  taking a manual pulse to detect AF
• Accurate diagnosis of AF using an ECG
• Further investigations and clinical assessment,
  including risk stratification for
  stroke/thromboembolism
• Development of a management plan rate-control,
  rhythm-control or referral
• Antithrombotic therapy as appropriate
• Follow-up and review

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AF care pathway
The management and presentation of AF involves
all healthcare settings
Primary/secondary/ emergency care
Primary/secondary care
Secondary/tertiary care
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Key priority detection and diagnosis
An ECG should be performed in all patients,
whether symptomatic or not, in whom AF is
suspected because an irregular pulse has been
detected
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Suggested actions

• People with undiagnosed AF can receive treatment
  sooner if opportunistic case finding is
  undertaken using manual pulse palpation
• Promote opportunistic case detection and
  targeting of patients at increased risk
• Primary care appropriate long-term condition
  registers, people aged gt65 years, flu vaccination
  programme
• Secondary care AE, outpatient clinics and
  wards, especially care of the elderly

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Suggested actions

• Remember to use ECG to confirm diagnosis and the
  routine recording of ECG results
• Review access to diagnostics irrespective of
  how services are structured locally, easy access
  and rapid reporting are essential
• Remember incentives and encourage practices to
  establish and maintain a practice-based AF
  register in line with the QOF 06/07 AF indicators
  
• Consider establishing a PCT-led, community-based,
  rapid-access arrhythmia clinic

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Key priority choosing the most effective
treatment

• Some patients with
• persistent AF will satisfy
• criteria for either an initial
• rate- or rhythm-control
• strategy
• Indications for each
• option are not mutually
• exclusive
• Involve the patient in the
• treatment decision
• Take comorbidities into
• account
• Antithrombotic therapy
• should always be used

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Treatment for persistent AF

• Two main treatment strategies
• Rate-control involves the use of chronotropic
  drugs or electrophysiological/surgical
  interventions
• Rhythm-control involves the use of electrical or
  pharmacological cardioversion for persistent AF,
  or suppression of recurrent (e.g. paroxysmal) AF
• There is still the need for appropriate
  antithrombotic therapy if a rhythm-control
  strategy is chosen

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Rate-control strategy

• Try rate control first for patients with
  persistent AF
• over 65
• with coronary artery disease
• with contraindications to antiarrhythmic drugs
• unsuitable for cardioversion
• without congestive heart failure

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Rhythm-control strategy

• Try rhythm-control first for patients with
  persistent AF
• who are symptomatic
• who are younger
• presenting for the first time with lone AF
• secondary to a treated/corrected precipitant
• with congestive heart failure

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Suggested actions

• Liaise with your local cardiac network benefit
  from shared learning and support. For example,
  some areas have established a primary care rapid
  access arrhythmia clinic and the provision of an
  arrhythmia care co-ordinator or an arrhythmia
  nurse specialist
• Provide awareness raising and education sessions
  for healthcare professionals dont forget to
  include out-of-hours services
• Develop, promote and disseminate quality patient
  information and decision aids for clinicians

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Key priority assess for risk of stroke and
thromboembolism

• Use the stroke risk
• stratification algorithm to
• assess risk of stroke and
• thromboembolism
• Use antithrombotic
• therapy as appropriate
• Initiate antithrombotic
• therapy with minimal
• delay in patients newly
• diagnosed with AF

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Patients with AF
Determine stroke/thromboembolic risk

• High risk
• Previous ischaemic stroke/TIA or thromboembolic
  event
• Age gt75 with hypertension, diabetes or vascular
  disease
• Clinical evidence of valve disease, heart
  failure, or impaired left ventricular function on
  echocardiography

• Moderate risk
• Age gt65 with no high risk factors
• Age lt75 with hypertension, diabetes or vascular
  disease

• Low risk
• Age lt65 with no moderate or high risk factors

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Patients with AF
Determine stroke/thromboembolic risk
Low risk
High risk
Moderate risk
Consider anticoagulation
Consider anticoagulation or aspirin
Aspirin 75 to 300 mg/day if no contraindications
Contraindications to warfarin?
YES
NO
Reassess risk stratification whenever individual
risk factors are reviewed
Warfarin, target INR 2.5 (range 2.0 to 3.0)
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Anticoagulation

• Assessment of bleeding risk should be part of the
  clinical assessment of AF patients prior to
  starting anticoagulation
• Antithrombotic benefits and potential bleeding
  risks of long-term coagulation should be
  explained and discussed with the patient
• Aim for a target INR of between 2.0 and 3.0
• Forms of monitoring include point of care or near
  patient testing and patient self-monitoring

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Suggested actions

• Review anticoagulation services locally
• Remember incentives for anticoagulation
  monitoring and near patient testing, e.g. QOF
  06/07 and National Enhanced Services
• Provide awareness raising and education sessions
  - emphasise stroke prevention and promote the use
  of the stroke risk stratification algorithm
• Consider integrating risk stratification into
  computerised patient management software
• Ensure provision of quality patient information

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Key priority optimise pharmacological
management
In patients with permanent AF, who
need treatment for rate-control beta-blockers
or rate-limiting calcium antagonists should be
the preferred initial monotherapy in all
patients
digoxin should only be considered as
monotherapy in predominantly sedentary patients
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Treatment for permanent AF

• The aim of heart rate control is to
• minimise symptoms associated with excessive
  heart rates
• prevent tachycardia-associated cardiomyopathy
• Digoxin monotherapy should only be useful for
  older, sedentary patients
• Perform a riskbenefit assessment to inform the
  decision of whether or not to give antithrombotic
  therapy

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Suggested actions

• Work with local Drugs and Therapeutics Committees
  and prescribing advisors to review and update
  prescribing formularies
• Emphasise clinically effective alternatives to
  digoxin to PCT prescribing advisors and
  prescribing leads
• Provide awareness raising and updating sessions
  for local primary and secondary care healthcare
  professionals

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Cardioversion

• Cardioversion is performed as part of a
  rhythm-control treatment strategy
• There are two types of cardioversion electrical
  (ECV) and pharmacological (PCV)
• Cardioversion of AF is associated with increased
  risk of stroke in the absence of antithrombotic
  therapy
• Not all attempts at ECV or PCV are successful
• Patient choice is important

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Treatment for paroxysmal AF

• Patients with paroxysmal AF can be highly
  symptomatic
• Three main aims of treatment for paroxysmal AF
  are to
• suppress paroxysms of AF and maintain sinus
  rhythm
• control heart rate during paroxysms of AF
• prevent complications
• Treatment strategies include out-of-hospital
  initiation of antiarrhythmic drugs pill in the
  pocket approach
• Patients with paroxysmal AF carry the same risks
  of stroke and thromboembolism as those with
  persistent AF

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Acute-onset AF

• Acute-onset AF requires immediate hospitalisation
  and urgent intervention
• Those at highest risk have a ventricular rate
  greater than 150 bpm, ongoing chest pain or
  critical perfusion

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Follow-up and referral

• Follow-up after cardioversion should take place
  at 1 month, and the frequency of subsequent
  reviews should be tailored to the patient
• Reassess the need for anticoagulation at each
  review
• Referral for further specialist intervention
  should be considered in patients
• in whom pharmacological therapy has failed
• with lone AF
• with ECG evidence of any underlying
  electrophysiological disorder

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Costs and savings

• Main elements identified as
• costs incurred due to increased use of ECG to
  confirm diagnosis
• increases in the use of anticoagulants in those
  with AF, which includes costs of additional
  anticoagulant services and of major bleeds
  incurred, and savings resulting from strokes and
  deaths avoided
  

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Access tools online

• Costing tools
• costing report
• costing template
• Audit criteria
• Implementation advice
• Available from www.nice.org.uk/cg036

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Access the guideline online

• Quick reference guide a summary
  www.nice.org.uk/CG036quickrefguide
• NICE guideline all of the recommendations
  www.nice.org.uk/CG036niceguideline
• Full guideline all of the evidence and
  rationale www.nice.org.uk/CG036fullguideline
• Information for the public a plain English
  version www.nice.org.uk/CG036publicinfo