Download Atrial Fibrillation / Atrial Flutter Management Pathway (AF)

North Wales Cardiac Network
Atrial Fibrillation / Atrial Flutter Management Pathway (AF)
New onset Atrial Fibrillation/Atrial
Flutter with symptoms <48 hours or
haemodynamically unstable
All chronic disease clinics or clinical suspicion of AF
 History and examination
 Manual pulse check
 If irregular pulse, perform an ECG to confirm
 Consider Heart Failure diagnosis requiring echo (not BNP) if ECG
has abnormal QRS or T waves but slowly control heart rate first.
Acute Medical admission
recommended
Further investigations:
 TFT, FBC,U&E, glucose, manual BP
 Pharmacological cardioversion
 Electrical cardioversion
 Ablation for flutter
Stroke Risk Stratification/thromboprophylaxis for all patients
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11646)
or CHA2DS2VASc score (see over)
Permanent
Accepted and
longstanding
Attempt rate control only
Long standing or persistent
Not self terminating, lasting > 7 days
up to 12 months (or more with previous
successful cardioversion)
Consider rhythm control if <65 years or
symptomatic with AF, secondary to a
treated corrected precipitant.
Otherwise use rate control
Management advice:
Start standard ß blocker (bisoporolol or
carvedilol) or rate limiting calcium antagonist
(Verapamil or Diltiazem) if no LVSD
 Titrate to achieve resting ventricular rate of <80
b.p.m. or <110b.p.m. on exercise
 Add digoxin for resting rate control if resting
Paroxysmal
Recurrent episodes lasting
usually <48 hours, max 7
days
Rhythm control
Identify trigger factors
(e.g. alcohol)
Management advice:
Start standard ß blocker (bisoprolol or carvedilol) or
rate limiting calcium antagonist (Verapamil or
Diltiazem) if ß blocker not tolerated and no LVSD
 Planned Electrical Cardioversion – use warfarin 3-4
weeks beforehand and at least 3 weeks after.
Refer for specialist opinion if patient still symptomatic.
Likely to be offered:
 Electrical cardioversion / EPS ablation so need warfarin initiation on referral. Amiodarone (permanent AF) or
Dronedarone (non permanent AF) can be used (short term <6/12) to increase success of ECV.
 Pharmacological “pill in the pocket” therapy may be useful for paroxysmal events.
The aim in all patients is to fully relieve all symptoms and for the stroke risk to be low.
Key:
Green = Primary Care
Red = Secondary Care
Yellow = Primary and Secondary Care
Issue 3
Rhwydwaith Cardiaidd Gogledd Cymru
North Wales Cardiac Network
Review Date: June 2013
Page 1 of 2
North Wales Cardiac Network 2011
Atrial Fibrillation / Atrial Flutter Management Pathway (AF)
Who needs Warfarin? Usually those with at least 1 other risk factor for stroke.
Annual risk of stroke is 1% per annum in the young and fit (5% over 5 years), increasing with age
and other risk factors for all types of atrial fibrillation and flutter.
The following links assist in the assessment of risk/benefit of warfarin treatment:
http://nntonline.net
Risk factors for stroke in non-valvular AF
Major risk factors
Previous stroke
TIA or systemic embolism
Age ≥ 75 years
Risk factor-based point-based scoring system –
CHA2DS2-VASc
Risk Factor
Clinically relevant non-major
risk factors
CHF or moderate to severe LV systolic
dysfunction (e.g. LV EF ≤ 40%)
Hypertension
Diabetes mellitus
Age 65-74 years
Female sex
Vascular disease
Adjusted stroke rate according to CHA2DS2-VASc
Score
Congestive heart failure/LV dysfunction
Hypertension
Age ≥ 75 years
Diabetes mellitus
Stroke/TIA/thrombo-embolism
Vascular disease
Age 65-74 years
Sex category (i.e. female sex)
Maximum score
1
1
2
1
2
1
1
1
9
Clinical characteristics comprising the HAS-BLED
bleeding risk score; if >3, need strict control of INR
CHA2DS2-VASc
score
Patients
(n = 7329)
Adjusted stroke
rate (%/y)
Letter
0
1
2
3
4
5
6
7
8
9
1
422
1230
1730
1718
1159
679
294
82
14
0%
1.3%
2.2%
3.2%
4.0%
6.7%
9.8%
9.6%
6.7%
15.2%
H
A
S
B
L
E
D
Clinical characteristic
Points
awarded
Hypertension
Abnormal renal and liver function ( 1
point each)
Stroke
Bleeding
Labile INRs
Elderly (e.g. age > 65 years)
Drugs or alcohol (1 point each)
1
1 or 2
1
1
1
1
1 or 2
Maximum 9
points
Patients with mitral stenosis, prosthetic heart valves or risk score >1 usually require warfarin.
Where antithrombotic therapy is given:
 The most effective treatment (reduces stroke risk by 2/3), is adjusted-dose Warfarin (target INR
2.5, range 2.0 to 3.0). USE WHOLE mg DOSES.
 Where Warfarin is not indicated, give aspirin 75 to 300 mg/day +/- clopidogrel 75mg daily (both
reduce stroke risk additively by 1/5 each). Consider gastroprotection.
 If Warfarin is appropriate, do not co administer aspirin purely for thromboprophylaxis, as it provides
no additional benefit. Aspirin may be continued if clearly indicated separately.
 Clopidogrel has a similar benefit to Aspirin but increases the bleeding risk when used concurrently.
Initiation of Warfarin:
 There is no need to achieve anticoagulation rapidly; a slow loading regimen is safe and achieves
therapeutic coagulation in the majority of people within 3-4 weeks.
 Ensure appropriate monitoring of INR using clinical support software. See BNF for potential drug
interactions.
Atrial Flutter: Rate and rhythm control can be more difficult
 DC cardioversion and / or ablation are more successful so earlier referral is indicated.
Issue 3
Review Date: June 2013
Page 2 of 2