Download NORTH OF ENGLAND CARDIOVASCULAR NETWORK ATRIAL

NORTH OF ENGLAND CARDIOVASCULAR NETWORK ATRIAL FIBRILLATION PATHWAY
Opportunistic case finding1
Symptomatic presentation
Emergency admission2
Acutely unwell,
rapid ventricular rate,
early cardioversion indicated
12 lead ECG confirmation
Examination and baseline investigations3
Diagnosis
1 Patients aged 65 and older should have a manual pulse palpation at least annually and any irregularity should be followed up with a 12 lead ECG
Consider ECHO5
Stroke risk assessment / initiation of stroke prevention4
For details please refer to the North of England Cardiovascular network guidelines: www.necvn.nhs.uk
2 Consider emergency hospital admission for patients with haemodynamic instability, heart failure, chest pain, breathlessness at rest, lightheadedness or syncope, stroke / TIA, rates in excess of 150bpm and wide QRS complexes. Patients considered for immediate cardioversion (clear history of AF onset within 48hrs)
If not confident refer to AF/arrhythmia clinic
3 Physical examination including manual BP evaluation, 12‐
lead ECG if not already carried out, FBC, U & Es, TFTs and LFTs, CXR if appropriate
Stroke prevention
4 See back for details
Refer: ‐ Symptomatic persistent AF
- Paroxysmal AF,
particularly young patients
and lone AF
‐ Mixed arrhythmias
‐ AF with structural abnormality6
Asymptomatic or acceptable symptoms
Treat as permanent AF
Rate
vs
Manage rate control7 in Primary Care
Refer to
AF/arrhythmia clinic8
8 Provision of primary AF services vary across the network and may be provided by specialist nurses, GPwSI or within cardiology departments
Not achieved
Annual follow up9 by CHD nurse / lead GP:
ECG, manual BP, drug review
Rate control
Follow up
6 Structural heart disease such as valve disease, heart failure, cardiomyopathy
7 Target heart rate at rest < 90bpm (<110 during exertion in sedentary individuals and 200 – age in active individuals). First line treatment: beta‐blockers or rate limiting calcium channel blockers
Rhythm
Achieved
5 Consider echocardiogram for patients with suspected structural heart disease (murmur, abnormal ECG etc.) and occasionally for refinement of stroke risk assessment
Sinus rhythm / rate control achieved
Therapy tolerated and stable
No – refer to electrophysiologist10
9 Needs to include review of stroke prevention and the appropriateness of the rate/rhythm strategy
10 For consideration of pulmonary vein isolation, pacemaker / AV node ablation or surgery
Stroke prevention is arguably the most important aspect of atrial fibrillation management
Warfarin is highly effective in reducing stroke risk but is greatly underused
AF as a Cause of Stroke
Does my patient need warfarin?*
Assessing stroke risk in AF patients
National Data
 The annual risk of stroke is 5‐6 times greater in AF patients than in people with normal heart rhythm
 18% of patients presenting with stroke are in AF at presentation. This equates to 16,000 strokes in England, of which 12,500 are thought to be directly attributable to AF
 Warfarin is highly effective in preventing stroke in AF, reducing risk of stroke by 64% compared to placebo
 Particularly in the elderly the risk of major haemorrhage is similar for Warfarin and Aspirin (1.9% vs 2.0% pa)
 Aspirin only reduces stroke risk by 22%
 Around 25 patients at high risk of stroke require warfarin treatment for one year to prevent one stroke
 The 2006 NICE guidance on AF costing report concluded that 46% of patients who should have been receiving warfarin were not
CHF
Hypertension
Age ≥75
Diabetes
Stroke /TIA
Risk category
0
Stroke Risk
% pa
1.9
1
2.8
2
4.0
3
5.9
CHADS2 Score
CHADS2 Score
1
1
1
1
2
CHADS2
score
4
8.5
5
12.5
6
18.2
HAS‐BLED bleeding risk score
Hypertension
>160mmHg
1
Abnormal renal and liver Creatinine >200,
1 or 2
function
ALT >3 x ULN
Stroke / TIA
1
Bleeding diathesis
1
Labile INR
1
Elderly (>65)
1
Drugs / alcohol
1 or 2
Exercise caution and review regularly if score ≥ 3
FALLS ARE NOT A MAJOR RISK FACTOR FOR BLEEDING
IN ANTICOAGULATED PATIENTS
Recommended stroke prevention
High
≥2
Oral anticoagulation (OAC)
Moderate
particularly if age > 65 & evidence of vascular disease
1
Either OAC or
Aspirin 75–325 mg daily
Preferred: OAC rather than Aspirin
No risk factors
and age < 65
0
Either Aspirin or no antithrombotic therapy
Preferred: no antithrombotic therapy
Absolute contraindications to Warfarin#
•
•
•
•
•
•
•
•
Hypersensitivity to warfarin
Within 2 days of surgery
Bacterial endocarditis
Intracranial haemorrhage
#this is not an Bleeding diathesis
exhaustive list
Existing or recent peptic ulcer
Uncontrolled hypertension >180mmHg
Pregnancy
* target INR 2‐3 with time in therapeutic range >65%
GRASP‐AF Query and risk stratification tool is FREE
and available for use with all GP clinical systems in England
Find further information at:
Important information for your patients:
www.atrialfibrillation.org.uk
 Do you know why you are taking warfarin, your target INR and the importance of attending for INR checks?
 It is important to tell your doctor and dentist that you are taking warfarin
 Before buying any medicines including alternative remedies tell the pharmacist that you are taking warfarin
 The concomitant use of aspirin, clopidogrel & warfarin or aspirin & warfarin may be appropriate in patients with coronary heart disease
 Any major changes in your diet may affect how your body responds to warfarin. If this exceeds a few days you should have an INR test
 Cranberry & grapefruit juice can affect your INR and should be avoided
 It is dangerous to ‘binge drink’ whilst taking anticoagulants
GRASP‐AF provides a set of MIQUEST queries to identify, for your practice, patients
with a diagnosis of AF who are not on warfarin
http://www.npsa.nhs.uk/nrls/alertsand-directives/alerts/anticoagulant
It calculates their risk of stroke using the validated CHADS2 scoring system and
highlights patients with a CHADS2 score of 2 or more who are not on warfarin and
would benefit from a review to assess the issue of anticoagulation.
www.stroke.org.uk
To find out more about this new tool and to sign up to run the search
simply go to www.improvement.nhs.uk/graspaf
Thanks to
Stroke Network
* For references please go to NECVN
website
Surrey Heart and