Download Rhythm Control Rate Control

Guidelines for the Management of Newly diagnosed Atrial
Fibrillation
Identify and Treat Major Primary Causes
ACS, Massive PE, Sepsis, Severe LRTI, Pericarditis, Metabolic / electrolyte
disturbance, Thyrotoxicosis, Drug effects / Toxicity
*These guidelines do NOT apply in the context of these conditions*
Haemodynamic Instability
- SBP < 90mmHg
- Hypoperfusion
- Hypoxaemia with AHF
Major Comorbid CVS Condition
Yes
- Congenital HD
- Cardiomyopathy
- Channelopathy
* See ALS Guidelines
- Cardiac transplant
- Pregnancy
- Severe COPD/ILD
Refer to Cardiology
No
O
< 48hr
IF ALREADY TAKING Class 1c OR Class 3
ANTI-ARRHYTHMIC DRUG
Rhythm
Duration of Atrial Fibrillation
Control
> 48hr
Rate
Control
Monitored bed ED / D55 / ACU
*Give Treatment dose Clexane if not
on VKA / NOAC
Manage on Medical Unit
Risk of Proarrhythmia
- ↑ BP and evidence LVH
- Previous MI or angina
- Known CCF
Ventricular Rate Control
Aim HR < 80bpm at rest and HR
<110bpm walking
No
O
iv Atenolol & iv
Flecainide
Yes
Consider IV
Amiodarone
vs urgent DC
Cardioversion
n
Pharmacological Cardioversion
< 48h from onset
No
O
Urgent DC
Cardioversion
Clinical Symptoms and signs of
heart failure
Yes
PO Digoxin
(or IV if NBM)
No
O
PO Atenolol
or if
contraindicated
PO Diltiazem
Yes
Discharge with
4 weeks NOAC
and Cardiology
OP follow up
Consult Thrombo-embolic
Prophylaxis Guidance if
CHADSVASC ≥ 2
Target HR Achieved
If not contact Cardiac ANP 7806731 or
CATS 70040, Cardiology SpR QMC
70090 or City 70091
Consult Thrombo-embolic
Prophylaxis Guidance
Thrombo-embolic Prophylaxis
The following chart is based on the European Society of Cardiology Guidelines (2010) for
the management of atrial fibrillation. The CHA2DS2VASc and HAS-BLED scores are the
most accurate risk indices for the risk of stroke and bleeding in this context. Calculate the
points for each of these risk scores and look up the advised strategy in the
anticoagulation therapy table using the key below:
No anticoagulation therapy recommended
VKA, NOAC or no anticoagulation therapy (NOAC preferred)
Consider VKA, or NOAC, or consult specialist
No anticoagulation therapy recommended
VKA or NOAC recommended
Atenolol (Oral)
Atenolol (IV)
Amiodarone (IV)
Digoxin (Oral)
Digoxin (IV)
Diltiazem (Oral)
(Angitil SR)
Flecainide (IV)
25 – 50mg od
Starting dose in elderly and
renal impairment should be
25mg.
2.5mg (repeat at 5-10 min
intervals up to a maximum
10mg dependant on BP and
Heart rate)
Loading dose: 300mg IV
over 1h into a central line or
large peripheral vein;
followed by 900mg over 23h
into a central Line
Loading dose dependent on
renal function. Usually two
doses of 500 micrograms 6h
apart
Usually dose of 500
micrograms. Additional
doses of 250 microgram
doses at 6h intervals up to
8-12 micrograms/Kg
90mg bd (60mg bd patients
who are elderly or have
renal impairment – see
below)
2mg/kg (maximum dose
150mg)
Drug
Administration
Orally
Give IV over 5 minutes
(0.5mg per minute). Give in
2.5mg doses leaving 10
minutes between bolus
doses
Loading dose 300mg IV in
250ml Dextrose 5% over 1h;
followed by 900mg in 500ml
Dextrose 5% over 23h.
Given via a central line or
large peripheral vein
Orally
Dilute in 100ml 5%Dextrose
,administer over 30 minutes
Dose Range
25 – 50mg od
5-10mg
Switch to oral amiodarone
62.5 – 250 micrograms od
Halve dose if patient also on
Amiodarone
IV loading dose may need to
be adjusted dependent on
renal impairment and body
wt. Dilute in 100ml Sodium
Chloride 0.9% administered
over 30 minutes
125 – 250 micrograms od
Halve dose if patient also on
Amiodarone
60mg- 180mg bd
2mg/kg (max. dose 150mg)
Onset of Action
2-4 hours
Immediate
Variable – may be 4-6 hours
0.5 to 2 hours
5 to 30 minutes
3 hours
Minutes
31 to 53 hours - affected by
renal impairment
31 to 53 hours - affected by
renal impairment
6 - 8 hours
7 – 19 hours
Usual Starting
Dose
Orally - The loading dose
will need to adjusted
dependent on renal
impairment
Half life
6-7 hours; Can be up to 1535 hours in renal impairment
6-7 hours
Variable 4.2 – 34.5 hours
Time for elimination can take
9- 44 days
Time to Peak
Concentration
3 hours
< 5 mins
Variable
2 to 6 hours
0.5 to 4 hours
4-6 hours
minutes
Duration of
Action
12-24 hours, may be
prolonged .e.g CKD
Up to 12 hrs
Variable. If patient fully
loaded the effects can last
for a month or greater
>24 hours
>24 hours
12 hours
4 hrs but can reduce
arrhythmias for between 624 hrs (av 13 hrs)
Renal
Impairment
Mild (Crcl=20-50ml/min) –
normal dose. Moderate (Crcl
10-20 ml/min)– maximum
dose of 50mg daily. Severe
(Crcl <10ml/min) – maximum
dose 25mg daily
One dose
No dose adjustment
necessary
60mg bd (Tildiem Retard)
Reduce dose by 50% if
creatinine clearance
<35ml/min
Main Contraindications
Acute decompensated LV systolic dysfunction
Cardiogenic shock
2nd/3rd degree AV block
Severe sinus bradycardia
Hypotension
Asthma/COAD
Monitoring
Pulse for Bradycardia
ECG
BP for hypotension
Blood sugars in diabetics
Bronchospasm especially in
asthmatics – see CI
Drug
Interactions
(See BNF)
Caution with concomitant
Diltaizem or Verapamil
Sinus bradycardia
2nd/3rd degree AV block
Thyroid dysfunction
Severe respiratory failure
Iodine hypersensitivity
Reduce doses in renal impairment.
See intranet for examples of doses in renal impairment
Ventricular Fibrillation
Pre –excitation syndromes eg:WPW
2nd/3rd degree AV block
Pulse for Bradycardia - may
be necessary to administer
IV atropine
ECG, BP for hypotension
Blood sugars in diabetics
Bronchospasm especially in
asthmatics – see CI
Baseline tests:
Heart rate, TFT’s
LFT’s, CXR and PFT’s for
patients with pulmonary
disease
ECG: QT prolongation
Pulse, renal function, keep K levels >4 mmols/L
Plasma levels should be checked where clinically indicated.
Signs of toxicity loss of appetite, nausea and vomiting,
diarrhoea, confusion, blurred or ‘yellow-coloured vision.
Digoxin levels checked pre-dose or >6h post dose
Caution with concomitant
Diltiazem or Verapamil
Monitor INR with warfarin.
Digoxin level may need to
be checked. Contraindicated with simvastatin
40mg or above. Can cause
QT prolongation, will interact
with other drugs.
Consult BNF
Consult BNF
Structural heart disease
including myocardial
infarction and cardiac failure
Hepatic impairment
Pulse for bradycardia
BP for hypotension
Caution with concomitant
beta-blockers
Left ventricular systolic
dysfunction
Cardiogenic shock
2nd/3rd degree AV block
Severe sinus bradycardia
Hypotension
Beta blockers
Correct electrolyte
disturbances before using
Flecainide
ECG monitoring
Caution with concomitant
anti-arrhythmic agents
Explanatory Notes for the Management of Newly Diagnosed Atrial
Fibrillation/Flutter Guidelines
Objective
These guidelines have been developed to improve the management of patients
with newly diagnosed atrial fibrillation (AF) and flutter (AFl). The guidelines
should be used in combination with clinical judgement to inform the clinical
decision making process.
The guidelines:
1. assist the clinician in acute management of the patient
2. include reference tables in order that the patient can make an informed
decision about stroke risk reduction
3. provide ‘at a glance’ information tables for the most commonly used drugs
4. provide clear instruction when referral to a cardiac specialist service is
indicated.
Scope of Guidelines
The guidelines are intended to assist clinicians managing patients with newly
diagnosed AF/AFL in the emergency department, acute medicine and other
medical specialties.
The guidelines do not pertain to AF/AFl in other contexts such as Primary
Pulmonary Hypertension (PPH), critical illness or post surgical AF/AFl including
coronary artery bypass grafting. However, the guidelines should be broadly
applicable to atrial fibrillation/flutter following uncomplicated elective non-thoracic
surgery.
The Guidelines - Algorithm (Page 1)
The first page of the guidelines provides an algorithm for AF/AFl management. A
list of important conditions associated with AF is provided which require referral
to cardiology. This is not an exhaustive list of AF/AFl causes and the clinician is
advised to perform a thorough medical assessment to identify other relevant
conditions.
It is important that the decision to assign the patient to a rhythm or rate control
strategy is made early by the admitting clinician and recorded in the medical
notes. The algorithm provides a recommendation on the appropriate strategy and
details the subsequent management.
Rate Control
All patients initially assigned to a rate control strategy on QMC campus should be
referred to the Cardiac Assessment Team (CATS) or Cardiac ANP and will be
reviewed on a standard working day within 24h on the ward. If the patient is to be
assigned to long term rate control strategy the patients will remain under the care
of the admitting clinician provided satisfactory ventricular rate control can be
achieved using the algorithm provided. If satisfactory rate control is not achieved
then the CATS / Cardiac ANP can be contacted to review the patient and advise
on further management. Patients at the City Campus should be referred to the
on-call Cardiology Registrar.
The patient may initially be assigned to rate control, perhaps because they
presented with asymptomatic AF/AFl or with AF/AFl >48h duration. In these
circumstances the patient may be deemed suitable for elective cardioversion and
the cardiology team will recommend and instigate the appropriate cardiac rhythm
management when the patient is reviewed.
Rhythm Control
Patients who are assigned to an initial rhythm control strategy will receive
medical or electrical cardioversion in the emergency department or in a
monitored bed within the cardiology unit. These patients will all be taken over by
the cardiology team. To reduce thromboembolic risk, a therapeutic dose of
enoxaparin should be administered when assigned to a rhythm control strategy.
It is recommended that those patients who are treated and discharged from the
emergency department without admission to hospital are discussed with the
emergency cardiology team and/or formally referred to the Arrhythmia Clinic.
Anticoagulation naïve patients should receive 4 weeks of NOAC upon discharge
to minimize risk of late thromboembolic complication.
The Guidelines - Thrombo-embolic Prophylaxis Reference Tables(Page 2)
For all patients assigned initially to a rate or rhythm control strategy it is
imperative that a senior member of the A&E or medical team decides with the
patient a plan for stroke risk reduction before discharge. This decision should be
documented, and the rationale for this if appropriate, recorded in the medical
notes.
In general, oral anticoagulation is underused in AF1 and page two of the
guidelines provides the clinician with evidence based data on stroke risk
reduction and bleeding risks associated with anticoagulant and antiplatelet
therapy. These risk scores are derived from large patient cohorts and are the
most accurate and applicable models available. All risk models/indices are
inherently imperfect and the ROC for the risk models provided is between 0.65
and 0.70. This means that the predictive accuracy that a bleeding event or stroke
will/will not occur in an individual patient is not greater than 70%. Notwithstanding
the tables should improve the quality of clinical information that can be given to
all patients so that an informed decision can be made with their doctor. Two
examples of how to use the tables is provided below.
CHA2DS2VASc Index
See Appendix 1 for definition of criteria.
Stroke risk in the CHA2DS2VASc include patients presenting with radiographically
proven strokes with neurological symptoms and signs, transient ischaemic
attacks and patients presenting with vague neurological symptoms suggestive of
cerebral ischaemia without confirmatory diagnostic tests2. Typically, up to one
third of patients with these diagnostic codes would develop disabling neurological
symptoms and signs but in the popoluation with AF/AFL this percentage may be
doubled. It is hypothesized that this is due to a greater number of strokes in the
AF/AFL population being secondary to a cardioembolic origin rather than noncardioembolic3. In the AF population 50% of strokes are thought to be
cardioembolic, 25% non-cardioembolic and 25% undetermined. The superior
efficacy of warfarin compared to aspirin is largely attributed to a reduction in
cardioembolic stroke. Therefore, although aspirin demonstrates efficacy in
thrombo-embolic prophylaxis, the effect on disabling cardioembolic stoke is not
established.
HAS-BLED Score
See Appendix II for definition of criteria.
There are several risk models available for predicting bleeding with oral
anticoagulation. The observed risks depend on the characteristics of cohort
selected. The HAS-BLED risk model4 is recommended by the European Society
of Cardiology guidelines for the management of atrial fibrillation 2010. This is
derived from nearly 4000 european patients in the EuroHeart Survey. The risk of
bleeding with aspirin and warfarin is similar. A HAS-BLED score >3 indicates a
high bleeding risk of bleeding but anticoagulants may still be appropriate and
may require careful monitoring.
Thrombo-embolic Prophylaxis Decision
In weighing the risk of major bleeding the clinician needs to consider the
predictive power of the HAS-BLED score and balance the risk of disabling stroke
against an acceptable risk of non-fatal and fatal bleeding. Additionally, the
clinician will appreciate that the models are a crude tool and a patients risk profile
does not transform as he/she passes a 75th birthday but increases in a more
linear pattern with advancing age. In some circumstances whether the patient
should be treated with aspirin or warfarin can be unclear and necessitates a
clinical judgment and discussion with patient. Such scenarios are relatively
uncommon and Cardiac Rhythm Management service can provide an opinion if
requested by the supervising consultant. If the clinician decides to prescribe
warfarin for the patient then in almost all cases this can be started as an
outpatient by the anticoagulation service.
Inpatient anticoagulation and/or heparinisation are only expected to be required
in exceptional circumstances such as those patients presenting with embolic
events or with evidence of an intracardiac mass. These patients are beyond the
scope of these guidelines and direct referral to the oncall cardiologist is more
appropriate.
The Guidelines - Drug Information Reference Table (Page 3)
The final page of the guideline provides drug information relevant to the
management of AF/AFl. The table highlights the most common and important
considerations. The tables will resolve most problems but are not exhaustive
and the clinician is advised to consult the British National Formulary
(http://www.bnf.org/bnf/) or contact the Pharmacist in Medicines Information if in
doubt.
Nottinghamshire
Area
Prescribing
Committee
AF
anticoagulation
prescriber decision support tool
The APC has clear guidance on which patients require continuing oral
anticoagulation for non-valvular atrial fibrillation. Within this document are
decision support tools to determine who requires oral anticoagulation, whether a
patient is more suited to a vitamin K antagaonist (ie. Warfarin) versus a noval
oral anticoagulant, and instructions on safe prescribing and monitoring.5
http://www.nottsapc.nhs.uk/attachments/article/3/anticoagulants%20in%20af.pdf
References
1. Lancet Neurol 2007; 6: 981–93
2. JAMA. 2001; 285(22):2864-2870
3. Cerebrovascular Disease 2000; 10:39-42
4. Chest 2010; 138:1093-1100
5. NUH / NAPC atrial fibrillation (non-valvular): prescriber decision support on
anticoagulation, 2015
Appendix I CHA2DS2VASc Risk Index 8
Score Letter Criteria
Definition
1
C
Chronic Heart
Failure/LV
Dysfunction
Including recent hospitalization with
decompensated HF ICD-9-CM codes
398.91, 402.01, 402.11, 402.91, 428.x, or
518.4 or moderate-severe LVSD
(LVEF<40%)
1
H
Hypertension
History of hypertension only
2
A2
Age
Age>75y
1
D
Diabetes
Diabetes mellitus (Insulin and non-insulin
treated)
2
S2
Stroke
Prior cerebral ischemia including stroke or
TIA
1
V
Vascular disease
Myocardial infarction, complex aortic plaque
and PAD, including prior revascularization,
amputation due to PAD, or angiographic
evidence of PAD)
1
A
Age
Age 65-74y
1
Sc
Sex category
Female gender
International classification of diseases Ninth and Tenth Revisio;n World Health
Organisation
http://whqlibdoc.who.int/icd/hq/1996/9_to_10.pdf
http://apps.who.int/classifications/apps/icd/icd10online/
Appendix II HAS-BLED Bleeding Risk with OAC
Score Letter Criteria
1
Definition
H
Hypertension
Systolic BP>160mmHg
1 or 2
A
Abnormal renal
and liver function
(1 point each)
Renal disease including chronic dialysis,
transplantation or creatinine>200Μmol/L.
Abnormal liver function includes cirrhosis or
significan LFT derangement including
bilirubin>2xULN or AST/ALT/AP>3xULN.
1
S
Stroke
Stroke
1
B
Bleeding
Previous bleeding history and/or
predisposition to bleeding, e.g. bleeding
diasthesis, anaemia, etc.
1
L
Labile INRs
Unstable INRs or TTR<60%
2
E
Elderly
Age>65y
1 or 2
D
Drugs/Alcohol
use
Concomitants use of antiplatlets or NSAIDs.
Alcohol use>8u/week
Review Date: December 2020