Download Definitions

Pathway for Diagnosis / Referral of Adults with
Palpitations presenting in Primary Care
Symptoms Present at time of
consultation
NO
YES
History, Exam
ECG, TFT, FBC
Associated with Presyncope /
Syncope, Chest Pain or SOB
Delta wave on ECG (WPW)
REFER CARDIOLOGY
PAF
See AF Management
High Cardiac Risk
Abnormal ECG
Chest pain / SOB / Syncope
YES
NO
Call 999 or Cardiac Arrest
Protocol
12 lead ECG
Sinus tachycardia (<120bpm)
Investigate for underlying
cause
Not sinus rhythm or AF
Atrial fibrillation
Try vagal manoeuvres
See AF Management
YES
REFER CARDIOLOGY
NO
Normal ECG etc
Single Episode
Reversion to sinus rhythm
REFER CARDIOLOGY
Consider medication if
recurrent
Recurrent Episodes
Continuing Tachycardia
NO FURTHER ACTION
REQUIRED
Symptoms < once a day
Symptoms daily
REQUEST OPEN ACCESS MEMO
if available *
OR REFER CARDIOLOGY
REQUEST OPEN ACCESS
24-HOUR TAPE if available *
OR REFER CARDIOLOGY
Single Ectopics only with no other symptoms – REASSURE
Couplets / Triplets / Salvos – REFER CARDIOLOGY
URGENT MEDICAL ADMISSION
Note: Recurrent worrying symptoms
unexplained by this pathway:
Cardiology advice can be sought
PAF - See AF Management
SVT REFER CARDIOLOGY
Sinus Rhythm with no other symptoms - REASSURE
ECN DS/SH FINAL 140907 8 pages
* Open
access memo or tape
If available locally, an aid to the correct
device is given in the accompanying
guidelines
Definitions
Palpitation: is the uncomfortable awareness of the heart rhythm. Normal palpitations occur with exercise, emotion and stress or after taking
substances that increase adrenergic activity or decrease vagal activity. Abnormal palpitations may occur for no reason and may be fast or strongand-slow. Palpitations may point to cardiac arrhythmia; however many with rhythm disturbances will not have palpitations, instead experiencing
syncope, shock and chest pain.
Syncope: is a sudden but brief loss of consciousness that is caused by inadequate blood supply to the brain. Recovery is spontaneous and rapidly
complete. Syncope is common, disabling and possibly associated with sudden cardiac death.
Vertigo: is a hallucination of movement of the environment about the patient, or of the patient with respect to the environment. It is not
synonymous with dizziness. It may be central - due to a disorder of the brainstem or the cerebellum - or peripheral - due to a disorder in the
inner ear or the Vlllth cranial nerve. Always would suggest ENT review prior to cardiac review unless associated with palpitations or chest pain
High Risk Factors:
 Pre existing structural heart disease
 History of heart failure
 History of syncope or presyncope
 FH of Sudden Cardiac Death under the age of 40yrs
 Exertion cardiac symptoms (including exertional palpitations)
 Resting 12 lead ECG abnormality (pre excitation, old MI, LBBB)
Vagal Manoeuvres:
 Valsalva Manoeuvre
 Carotid Sinus Massage (if practitioner feels competent and no bruits present)
 Face immersion in cold Water
Common Situations:
 Palpitations as missed beats or non sustained runs occurring predominately at rest or at night are suggestive of PVE needing no
intervention if there are no other risk factors of cardiac disease
 If the attacks are occurring less than once a week without associated 'High Risk Factors' ambulatory monitoring is unlikely to be of
assistance. If High Risk Factors are present formal referral is suggested.
• Asymptomatic bradycardia in the elderly (resting heart rate in mid 40s) do not need intervention
 Syncope without preceding palpitation, or occurring less then once a week, investigation with a 24hr ECG is rarely helpful
Investigation of symptoms - Cardiomemo or 24 hour tape?

A cardiomemo is a patient activated event recording device that is generally provided for 5 to 7 days. It is helpful for infrequent
symptoms and is recommended for patients who have symptoms less than once a day but more frequent than once a fortnight

A 24 hours tape allows continuous heart rhythm monitoring for 24 hours. It is indicated where there are symptoms on a daily, or
near daily, basis
ECN DS/SH FINAL 140907 8 pages
Atrial Fibrillation accounts for approximately 70% of all Arrhythmia Presentation in Essex.
Therefore it was felt essential to include all types of presentations of AF in the following
pathways.
The guidance includes advice on Risk stratification and Rate versus Rhythm Control.
New Diagnosis Atrial Fibrillation Care Pathway
Page 4
Treatment Strategy for Atrial Fibrillation
Page 5
Rate versus Rhythm Control
Page 6
Stroke Risk Stratification
Page 6
Primary Care Management Guideline for
Permanent Atrial Fibrillation with Known Aetiology
Page 7
Haemodynamically Unstable & Acute Onset Atrial Fibrillation
Page 8
3 ECN DS/SH FINAL 140907 8 pages
New Diagnosis Atrial Fibrillation Care Pathway
If Previous Diagnosis of AF – see Treatment Strategy
No symptoms – opportunistic
case-finding leads to clinical
suspicion of new AF
Symptomatic presentation
and clinical suspicion of
new AF
Confirm Diagnosis
History
Examination
Manual Pulse
12 lead ECG
Emergency referral to
A&E If patient is
Haemodynamically unstable
Start treatment if ventricular
Rate > 90 bpm
For Example
Beta Blockers
Rate Limiting Calcium Antagonist
Digoxin
Referral to Local Rapid Access Arrhythmia Clinic
or Equivalent
ECHO (if appropriate)
FBC, UE, LFT & Thyroid function
Stroke Risk Stratification
Management Plan
Follow Up
Sinus Rhythm
Assess need for further
maintenance / monitoring
Continued AF
Continued FU /
Monitoring
Return of symptoms / AF
Referral for further
Electrophysiology Advice
4 ECN DS/SH FINAL 140907 8 pages
Treatment Strategy for Atrial Fibrillation
Confirmed Diagnosis of
Atrial Fibrillation
Further investigations and clinical assessment including
Stroke Risk Stratification
Paroxysmal AF
Persistant AF
Permanent AF
OR
Rate Control
Refer to permanent AF
with Known Aetiology
Rhythm Control
Continued Symptoms or
Failure of Rate or Rhythm Control
EP Consultant Referral
Classifications:
All AF lasting greater than 30 seconds should be described as:
Paroxysmal – if self terminating within 7 days
Persistent – if cardioverted to Sinus Rhythm by any means or lasts >7days regardless of how it
terminates
Permanent – if it does not terminate or relapses within 24 hrs of cardioversion
5 ECN DS/SH FINAL 140907 8 pages
Rate versus Rhythm Control
Rate Control
Rhythm Control
Contraindication to Cardioversion

Patients over 65



Presenting for the first time
with lone AF
Contraindications to
anticoagulation
Patients with coronary
heart disease

Younger patients

Structural heart disease that
precludes long term
maintenance of sinus rhythm

Long duration of AF ( > 12
months )

Multiple failed attempts of
cardioversion

Ongoing but reversible cause

Patients unsuitable for
cardioversion

Patients with Congestive
heart failure

Patients with
contraindications to
antiarrhythmic drugs

On going symptomatic
patients despite rate
management
Without congestive heart
failure


Patients with AF secondary
to a treated/corrected
precipitant
Stroke Risk Stratification – there are two systems of risk evaluation
The CHAD2 score-if the score is over 2 formal Anticoagulation suggested
CHAD2 Item
Congestive Heart Failure
Hypertension
Age over 75
Diabetes
Prior cerebral ischaemia
The NICE Guidance – 2006
6 ECN DS/SH FINAL 140907 8 pages
Points
1
1
1
1
2
Primary Care Management Guideline for
Permanent Atrial Fibrillation with Known Aetiology
Annual Drug Review
Warfarin
Ensure NO side-effects and possible drug
interactions eg. Non-steroidals, Aspirin and
Clopidogrel *
Medication for
Rate Control
Those on Long Term Amiodarone should have a recorded
reason documented from a cardiologist or AF Clinic, as this
drug is rarely given to patients with permanent AF.
Amiodarone
Those on Amiodarone long term require:
 6 monthly TFT
 Annual opticians eye screen and refer if corneal
microdeposits develop
 CXR if respiratory symptoms develop
 Associated hepatotoxicity - advise at least annual
LFT. Stop amiodarone if develop signs of liver
disease
*Patient’s on Aspirin, Clopidogrel and Warfarin should be reviewed by a cardiologist to see if all
three need to be continued
Annual Rate & Rhythm Review
Check Heart Rate & Rhythm with
Annual ECG
Atrial Fibrillation
Sinus Rhythm
Target Rate Control = 60-80 bpm at rest
1st Line: Beta-Blockers
2nd Line: Diltiazem / Verapamil
Digoxin: First line for sedentary patients
Exclude Paroxysmal AF with Cardiomemo. If
results show Sinus Rhythm throughout
consider stopping Warfarin.
Check that Cardiologist or AF clinic hasn’t
suggested Long Term Warfarin.
7 ECN DS/SH FINAL 140907 8 pages
Haemodynamically Unstable & Acute Onset Atrial Fibrillation
Patients with acute haemodynamic
instability secondary to AF
Is the situation life – threatening ?
NO
YES
Is Duration of AF
> 48 Hrs ?
NO
Emergency Electrical
Cardioversion
YES
Consider
Pharmacological or Electrical
Cardioversion
+
Stroke Risk Stratification
Pharmacological rate – control
+
Stroke Risk Stratification
Refer to Local Rapid Access Arrhythmia Clinic
or Equivalent
8 ECN DS/SH FINAL 140907 8 pages