Download Rapid Access Atrial Fibrillation/Flutter Clinic

New Atrial Fibrillation/Flutter
Pathway and GRASP Tool
Kay Elliott
Arrhythmia Nurse Specialist
Dorset County Hospital NHS
Foundation Trust
NEW ONSET ATRIAL
FIBRILLATION/FLUTTER
New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell?
Yes
Admit to hospital
Rate or Rhythm control strategy initiated and
discharged back to primary care with followup/onward referrals if required. Patients
requiring DC Cardioversion referred to
AF/Flutter Clinic
No
See next slide
Primary Care
Initiate appropriate stroke/TIA prophylaxis according to CHADS–VASc score (BOX A)
and Initiate appropriate rate control (BOX B)
BOX A: CHADS–VASc Scoring
Risk Factor
Point
Heart Failure/LV Dysfunction
1
Hypertension
1
Aged > 75
2
Diabetes mellitus
1
Stroke / TIA
2
Vascular disease
1
Age 65-74
1
Female
1
CHADS–VASc Result:
0 = Aspirin 75mg – 325mg daily or no antithrombotic
therapy (preference for no therapy)
1 = Either OAC or aspirin (preference for OAC rather than
aspirin)
> 2 = OAC recommended
Box B: Rate control
First Line:
Beta-blocker (e.g. Bisoprolol) or a rate limiting
calcium antagonist (e.g. Diltiazem), if beta-blocker
contraindicated
Second Line:
Digoxin – additional to optimise rate control, where
required. As monotherapy only in predominantly
sedentary patients.
Paroxysmal
NEED FURTHER
ADVICE?
Persistent
ARRHYTHMIA NURSE:
01305 254920
Refer to cardiology team: referral
letter or choose and book
Cardiologist
Appropriate strategy initiated
with onward plan/referrals
made. Patients requiring DC
Cardioversion referred to
AF/Flutter Clinic
Fax Dorset County Hospital intranet or by
contacting BHF Arrhythmia Nurse) referral to
Rapid Access Atrial Fibrillation/Flutter Clinic.
(Form attached. Also available on the intranet
Rapid Access Atrial Fibrillation/Flutter Clinic
ECHO AND ECG
BHF ARRHYTHMIA NURSE CLINIC:
Review history, symptoms, test and examination results
Patient education
Agree treatment plan: Rhythm or Rate control
Arrange ongoing follow-up, where required
Referral to cardiology clinic if other cardiac issues identified
Rhythm
Control
Arrhythmia Nurse Specialist; arrange
DC Cardioversion and/or, if indicated:
Refer to electrophysiology centre for
ablation
Rate
Control
Manage long-term
warfarin and rate-control –
Primary Care
Prepare for DC Cardioversion:
Weekly INR (Target 2.5-3.0), must have INR >2.0 for four full weeks prior to DC
Cardioversion
DC Cardioversion – DAY SURGERY UNIT
Procedure and review of medications/onward management plan (Arrhythmia
Nurse and Cardiology Specialist Registrar) pre discharge
4 Weeks post procedure: Follow-Up with Arrhythmia Nurse
Is the Patient in Sinus Rhythm and are their symptoms improved/satisfactory?
Yes
6 Months post procedure: Follow-Up
with Arrhythmia Nurse
Is the Patient in Sinus Rhythm and are
their symptoms improved/satisfactory?
Cont...
No
Depending on clinical indications
and patient preference either:
Re-attempt DC Cardioversion with
additional AA cover (amiodarone)
Refer for ablation
Rate control/Warfarin - (primary Care)
Refer to Cardiologist if patient has
ongoing symptoms or complications
6 Months post procedure: Follow-Up with Arrhythmia Nurse
Is the Patient in Sinus Rhythm and are their symptoms improved/satisfactory?
Yes
Discharge to primary care
and patient advised to
seek medical attention if
symptoms recur
No
Depending on clinical indications
and patient preference either:
Re-attempt DC Cardioversion with
additional AA cover (amiodarone)
Refer for ablation
Rate control/Warfarin - (primary Care)
Refer to Cardiologist if patient has
ongoing symptoms or complications
Anti-coagulation post DC Cardioversion:
Maintaining a therapeutic INR during the four weeks post DC Cardioversion is essential for
All patients regardless of their CHADS–VASc score.
Advice with regards to long-term anti-coagulation is based on patients’ CHADS–VASc
score rather than the presence of sinus rhythm/absence of atrial fibrillation/flutter on
ECG/Holter.
Over to You – Any Questions?