Download Atrial fibrillation community clinic referral form

ATRIAL FIBRILLATION COMMUNITY CLINIC REFERRAL FORM
Please use in conjunction with SLCSN Atrial Fibrillation Pathway for Primary Care
Email your referral to………………..
Patient Details
Title
Surname
First Name
Address
Referral date:
Referrer Details (Stamp)
NHS Number:
Date of Birth
Age
Gender
Telephone (Home/mobile/work)
Is an interpreter required? Y/N
If so, which language?
Patient needs transport please? Y/N
MANDATORY INFORMATION
INAPPROPRIATE REFERRALS
(Incomplete form will be returned)
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AF documented on ECG or Holter monitor
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ADMIT ACUTELY AF patient with:
(Evidence MUST be attached)
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CHADS2 score:
CHA2DS2VASc (if CHADS2 =1):
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HAS-BLED score:
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Blood tests:
TSH:
T4:
ALT/SGPT:
Hb:
Glucose:
HbA1c:
Creatinine:
eGFR:
Haemodynamic compromise, breathlessness at rest,
syncope, dizziness
Chest pain, stroke, TIA, rate>150bpm
Consider admission for recent AF onset, especially if
within 48 hrs & not anticoagulated for early DCCV
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Patient with AF under Cardiologist care
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AF & Heart failure: HF services might be more
appropriate especially if already under care.
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AF & pregnancy: please refer to Dr M. Cooklin
(GSTT) or Dr F. Murgatroyd (king's).
Past Medical History & Medication(s): please provide a medical record extract, including anticoagulation history.
Why are you referring this patient? (See referral guidance)
Y/N
Please give any relevant details
Newly diagnosed AF:
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Young patient (age < 65)
Paroxysmal AF
Lone AF
Persisting AF secondary to a trigger/substrate
that has been corrected
AF with abnormal ECG
AF with structural heart abnormalities
Patient with known AF and "treatment challenge":
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Patient symptomatic despite medical treatment
Difficult or failed rate control
Difficult anticoagulation decision
Atrial flutter
Are you referring for another specific reason?
If NO to all above questions why would you like your
patient to be seen?
If this referral is not accepted for the nurse led AF clinic would you be happy for this referral to be
considered for a consultant lead cardiology appointment? Y/N
ATRIAL FIBRILLATION COMMUNITY CLINIC - Referral guidance
Referral criteria – definitions:
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Paroxysmal AF: self-terminating, usually within 48hr or less than 7 days.
Lone AF: AF without overt structural heart disease, defined as,
 Minimum standard: no PMH of CVD or hypertension, normal heart examination (e.g. no heart murmur), normal chest
x-ray & normal ECG (i.e. no indication of prior MI or LVD)
 Optimal standard: above plus normal echocardiography (normal atria, valves and LV size and function)
Persisting AF secondary to a trigger/substrate that has been corrected: i.e. acute infection, hyperthyroidism, high
alcohol intake…
AF with abnormal ECG: consider any evidence of
 Previous MI or LVH, Significant T wave inversion,
 LBBB, pre-excitation, QTc interval > 460ms, 2o/3o heart block.
Please be aware of red flags: e.g. acutely unwell, exercise induced syncope and refer to SLCSN arrhythmia traffic light
guideline.
AF with structural heart abnormalities: consider any evidence of IHD, valve disease and cardiomyopathy.
Patient symptomatic despite medical treatment: i.e. palpitations, SOB…
Difficult or failed rate control:
 Defined as target pulse rest >80 bpm or >110 bpm during moderate exertion (>110 bpm for sedentary individuals)
despite optimal or maximum tolerated dose of β-Blockers (Bisoprolol first line) or rate limiting calcium channel
blockers (Diltiazem or Verapamil)
 A lenient target rate control (pulse rate <100 bpm at rest) could be appropriate in some patients. Please do seek
cardiologist opinion.
Difficult anticoagulation decision: any patient with CHADS2>1 or CHA2DS2VASc >1 in whom oral anticoagulant is
indicated but with any of the following (non exhaustive)
 HAS-BLED score >3 or HAS-BLED > CHADS2 score
 Increase risk of bleed due to concomitant medications: i.e. Aspirin, NSAIDs…
 Clinician reluctance to offer anticoagulation
 Patient declined recommended anticoagulation
Important suggested steps before you refer1:
(Also refer to SLCSN Atrial Fibrillation Pathway for Primary Care)
1. Confirm diagnosis: any arrhythmia that has the characteristic of AF (irregularly irregular QRS without consistent P waves)
and last at least 10 seconds on ECG, 24Hr ECG or Holter.
2. Assess tolerance & severity of symptoms
3. Physical examination: manual BP, cardiac auscultation (murmur), sign of HF/Thyrotoxicosis.
4. Relevant PMH & search for possible precipitant:
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PMH: Cardiovascular (Hx of stroke, TIA, amaurosis fugax, diabetes, CAD, HF), Gastro-intestinal (bleed, ulceration,
dyspepsia), bleeding diathesis.
Precipitant: eg sepsis
5. Try to establish duration of AF: allows temporal classification of AF (i.e., recent, paroxysmal, persistent / more than 7
days or requiring termination by cardioversion either by drug or DCC, permanent) and guide management. Unless
symptomatic AF and or with an identifiable specific precipitant (i.e. chest infection, surgery) it is often very difficult to
determine. Practically:
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Onset less than 48hr warrant {? consider} immediate admission for cardioversion, particularly if not already
anticoagulated or patient very symptomatic (anticoagulation required thereafter).
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Paroxysmal AF: if persisting more than 48hr spontaneous conversion is unlikely. Anticoagulation must be considered.
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If AF duration over 12 months, DCC is unlikely to be effective.
6. Investigations: FBC, U&E, TFTs, LFTs, Glucose & HbA1c, CXR if appropriate. Echocardiography if suspected structural
heart disease or refinement of stroke risk assessment.
7. Assess stroke risk: use CHADS2 score (CHA2DS2VASc if CHADS2 =1). Available at Stroke risk calculator
8. Assess bleed risk: use HAS-BLED risk score. Available at HAS-BLED risk score
9. If appropriate, initiate or refer to anticoagulation clinic: OAC should not be denied without seeking an expert
opinion.
10. Start rate control: if confident, start a β-blocker (Bisoprolol) or a rate limiting calcium channel blocker, low dose with uptitration to a target rest heart rate <80bpm, especially if patient symptomatic at presentation. This will also help better
echocardiography imaging acquisition.
1 Health
R, Lip G.Y.H (2008) Ten steps before you refer for AF, BJC, 302-305, 14 (6)