Download Supporting patients with atrial fibrillation/flutter

Supporting patients
with atrial
fibrillation/flutter
Rapid access atrial
fibrillation/atrial flutter
clinic
& pathway
Arrhythmia Nurse Specialists – DCHFT
01305 254920
[email protected]
Aims of the AF/Flutter
Clinic

prompt and comprehensive assessment

streamlined care pathway

patients offered appropriate education and support

onward management plan is agreed

timely DCCV procedure, when this is the treatment
strategy of choice
Referral
From Primary Care:
New onset persistent atrial fibrillation/flutter, confirmed with 12 lead ECG
From Secondary Care:
New onset persistent atrial fibrillation/flutter, confirmed with 12 lead ECG
and suitable for DCC
Exclusion criteria
Known/long standing AF
 Patients with Paroxysmal AF
 Not suitable for rhythm control strategy; rate controlled and
symptom free

Atrial Fibrillation/Flutter
Pathway
START anticoagulation & rate control

See Draft pathway and refer as appropriate

For further advice call:
Arrhythmia Nurse specialists on 01305 254920
or email: [email protected]
Atrial Fibrillation/Flutter
Clinic Review

ECG

Echo

Patient assessment and examination

Anticoagulation issues

Rate and rhythm control

Pre-clerk for DCCV (when treatment of choice)

Further tests (if required) and follow-up

Patient education and support

Clinic letter to their referrer
2006-2016

Arrhythmia service continued to grow

Trend towards rate control

Waiting times for AF/Flutter clinic, now mostly
within 30 days

Fast tracking to DCCV (waiting times and
NOAC)
Final points

Good quality ECG – confirm AF/Flutter

anticoagulation

rate control

call/email for advice if needed

Post DCCV – anti-coagulation based
on CHA2DS2VASc score
Latest AF guidelines
& Practical issues when
using NOAC/DOAC’s
Management Goals
Atrial Fibrillation
Exclude/treat
underlying cause
Reduce
Thromboembolic risk
Prevent
circulatory instability
Rate/rhythm
Control
Heart Rate Control in
Atrial Fibrillation
Beta-blocker
Diltiazem (if beta-blocker contraindicated)
Digoxin as an additional agent to optimise rate control,
where required or as monotherapy only in predominantly
sedentary patients
Digoxin Toxicity
Risk of Toxicity Increased with:
Medications: Calcium Channel Blockers, Quinidine,
Amiodarone, Diuretics, Propafenone, Indomethacin)
Age
Electrolyte imbalance: Hyper/hypokalaemia,
hypomagnesemia, hypercalcaemia and hypernatraemia
Metablolic problems: Hypothyroidism, hypoxaemia and
alkalosis
On-going Symptoms?
Refer people promptly at any stage if treatment
fails to control the symptoms of atrial fibrillation
and more specialised management is needed.
https://www.nice.org.uk/guidance/cg180/chapter/key-priorities-for-implementation#/ftn.footnote_1
Calculate stroke risk score with:

symptomatic, asymptomatic, paroxysmal, persistent
or permanent atrial fibrillation

atrial Flutter

a continuing risk of arrhythmia recurrence after
cardioversion back to sinus rhythm
Do not offer Aspirin monotherapy solely for stroke
prevention to people with atrial fibrillation
*National Clinical Guideline Centre (NCGC) 2014
**The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC - 2012)
Stroke Risk:
CHA2DS2-VASc Score
C
H
A
D
S
V
A
Sc
Congestive heart failure?
Hypertension
Age >75 yrs
Diabetes
Stroke ,TIA or thromboembolism
Vascular disease
Age 65-74
Sex category (female)
1
1
2
1
2
1
1
1
Points
(max 9)
Don’t wait for the echo to calculate the score/initiate anti-coagulation
1 point for female gender alone would NOT be an indication for anticoagulation
Stroke risk
CHA2DS2-VASc Score
Ensure that anticoagulation is discussed and offered
to individuals with:
 a score of ≥2
 considered for all those with a score of 1 (except if they are aged <65 yrs
and the point is due to female gender alone)
(NICE, CG180)
Stroke risk
CHA2DS2-VASc Score
A score of 0 (or 1 for females)
no anticoagulation (bleeding risk with
anticoagulation is deemed to be higher than their stroke risk)
Individuals with AF and underlying cardiac issues such as
valvular heart disease or cardiomyopathies may require long
term anticoagulation irrespective of their CHA2DS2-VASc score
Those being prepared for cardioversion or AF ablation will also
be anticoagulated prior to and after the intervention
(NICE, CG180)
Bleeding Risk: HAS-BLED
H
A
S
B
L
E
D
Hypertension
Abnormal renal and liver function*
Stroke
Bleeding
Labile INRs
Elderly >65years
Drugs eg aspirin, NSAID, alcohol*
1
1 or 2
1
1
1
1
1 or 2
*1 point each.
A Score >=3 indicates high risk
Therefore, caution required with either anti-platelet or oral
anticoagulant therapy
Bleeding Risk: HAS-BLED

A score of >3 indicates that caution and regular review
are appropriate

The score per se should not be used to exclude patients
from anti-coagulation

Need to address the correctable risk factors for bleeding
Poor anticoagulation control
•
2 INR values higher than 5 or 1 INR value higher
than 8 within the past 6 months
•
2 INR values less than 1.5 within the past 6
months
•
Time in treatment range less than 65%
Atrial fibrillation: the management of atrial fibrillation NICE clinical guideline 180
© NICE 2014. All rights reserved. Last modified June 2014 Page 16 of 49
Address factors that may
contribute to poor INR control:

cognitive function

adherence to prescribed therapy

illness

interacting drug therapy

lifestyle factors including diet and alcohol
consumption
NOAC’s (Non vitamin K Oral Anti-Coagulants)
Or DOAC’s (Direct Oral Anti-Coagulants)
•
At least as effective as Warfarin
•
Lower risk of intracranial haemorrhage
•
Higher risk of GI bleeding (Dabigatran, Rivaroxaban & Edoxaban)
•
Rapid onset/short half-life
•
Renal function issues
•
Do not need to monitor INR
•
Do need to monitor (see next slide)
Not for patients with Valvular AF; those with
mechanical heart valves and mitral stenosis
Direct Oral AntiCoagulants
Factor Xa inhibitors
Direct thrombin
inhibitor
apixaban
edoxaban
rivaroxaban
dabigatran
Choosing an anti-coagulant
and correct dose
Consider:

indication (and does the patient meet the licensing indication?)

patient preference and concordance issues

co-morbidities

renal and liver function

age

weight

concomitant medications

contraindications
Estimating creatinine
clearance
HTTP://WWW.MDCALC.COM/CREATININE-CLEARANCE-COCKCROFTGAULT-EQUATION
Apixaban:
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)
The recommended dose of apixaban is 5 mg twice daily
Reduce to apixaban is 2.5 mg twice daily with severe renal impairment
(creatinine clearance 15-29 mL/min)
OR
in patients with NVAF and at least two of the following characteristics:

age ≥ 80 years,

body weight ≤ 60 kg,

or serum creatinine ≥ 1.5 mg/dL (133 micromole/L).
Use is not recommended in patients with creatinine clearance < 15 ml/min
Dabigatran:
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)
The recommended dose of dabigatran is one 150 mg capsule twice daily
Reduce dose of Pradaxa to one 110 mg capsule twice daily in:
• Patients aged 80 years or above
• Patients who receive concomitant verapamil
The daily dose of Pradaxa of 300 mg or 220 mg should be selected
based on an individual assessment of the thromboembolic risk and the
risk of bleeding:
• Patients
between 75-80 years
• Patients with moderate renal impairment
• Patients with gastritis, esophagitis or gastroesophageal reflux
• Other patients at increased risk of bleeding
Exclude patients with severe renal impairment (i.e. CrCL < 30 mL/min). Pradaxa is
contraindicated in patients with severe renal impairment
Edoxaban:
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)
The recommended dose is 60 mg edoxaban once daily.
The recommended dose is 30 mg edoxaban once daily in patients with one
or more of the following clinical factors:

Moderate or severe renal impairment (creatinine clearance (CrCL) 15 50 mL/min)

Low body weight ≤ 60 kg

Concomitant use of the following P-glycoprotein (P-gp) inhibitors:
ciclosporin, dronedarone, erythromycin, or ketoconazole.
exclude patients with end stage renal disease (i.e. CrCL < 15 mL/min),
Rivaroxaban:
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)
The recommended dose is 20 mg once daily, which is also the
recommended maximum dose
In patients with moderate (creatinine clearance 30 - 49 ml/min) or
severe (creatinine clearance 15 - 29 ml/min) renal impairment the
recommended dose is 15 mg once daily
Use is not recommended in patients with creatinine clearance < 15 ml/min
Rivaroxaban:
Due to a reduced extent of absorption an oral bioavailability of 66% was
determined for the 20 mg tablet under fasting conditions. When Xarelto 20
mg tablets are taken together with food increases in mean AUC by 39%
were observed when compared to tablet intake under fasting conditions,
indicating almost complete absorption and high oral bioavailability.
Rivaroxaban 15 mg and 20 mg are to be taken with food
How to DOACs effectively
Apixaban
One tablet twice daily (every 
12 hours)


Swallow the tablet whole with a glass of water
It can be taken with or without food.
Do not crush the tablets
Rivaroxaban
One tablet once daily

(at the same time of the day) 
Swallow the tablet whole with a glass of water
Dabigatran
One capsule twice daily
(every 12 hours)






It needs to be taken with food to work
properly
Sit in an up-right position.
Peel back foil to remove capsule, do not push it
through the blister pack.
Do not open the capsule.
Swallow the capsule whole with a glass of water.
Taking with food may help reduce the possibility of
stomach irritation.
Only break the foil and remove a capsule when you
are ready to take it, so that it is not affected by
moisture in the air.
Swallow the tablet whole with a glass of water.
It can be taken with or without food.
Edoxaban
One tablet once daily

(at the same time of the day) 
Warfarin
As per yellow warfarin book and clinic support.
Audit suggestions
High Risk - CHA2DS2 VASc >2 not on anticoagulation
including those on antiplatelet; review if suitable for warfarin/NOAC
Moderate risk
CHA2DS2 VASc =1 male only, not currently on
anticoagulation; consider warfarin/NOAC
Low risk
CHA2DS2 VASc = 0; review reason if on anticoagulant or antiplatelet
drug
Also
•
All people on antiplatelet AND anticoagulation, should both be continued?
•
Those on anti-arrhythmic drugs such as Amiodarone – regular review
indicated
Useful Resources

Keele University anticoagulation tool:
http://www.anticoagulation-dst.co.uk/

AHSN anticoagulation tool:
www.dontwaittoanticoagulate.com/

Medcalc: for cha2ds2vasc/HASBLED/creatinine clearance:
http://www.mdcalc.com/cha2ds2-vasc-score-for-atrial-fibrillationstroke-risk/
http://www.mdcalc.com/creatinine-clearance-cockcroft-gaultequation
Useful Resources continued…..
UPDATED EUROPEAN HEART RHYTHM ASSOCIATION PRACTICAL GUIDE ON THE USE OF NONVITAMIN K ANTAGONIST ANTICOAGULANTS IN PATIENTS WITH NON-VALVULAR ATRIAL
FIBRILLATION
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (NICE), NATIONAL CLINICAL
GUIDELINE CENTRE (2014) ATRIAL FIBRILLATION: THE MANAGEMENT OF ATRIAL FIBRILLATION.
CLINICAL GUIDELINE 180. METHODS, EVIDENCE AND RECOMMENDATIONS. JUNE 2014.
COMMISSIONED BY THE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (FULL
VERSION AND KEY RECOMMENDATIONS).
2016 ESC GUIDELINES FOR THE MANAGEMENT OF ATRIAL FIBRILLATION DEVELOPED IN
COLLABORATION WITH EACTS
Any Questions?