REMEDY : BNSSG referral pathways

Atrial Fibrillation

Checked: 17-01-2018 by hana.cavill Next Review: 17-12-2018

Principles of Management

If a patient presents with significant symptoms or a complication of AF, admit patient or discuss with on call cardiologist  (see red flags section below)

For patients not requiring admission then initially identity and manage any underlying cause or trigger. Uncomplicated Atrial Fibrillation can often be managed in primary care. The following advice is based on NICE guidelines and advice from Ed Duncan - consultant cardiologist at UBHT. 

Diagnosis

  • If an irregular pulse is detected then arrange an ECG. 

  • If paroxysmal AF is suspected and an initial ecg is normal then organise an ambulatory ecg. This can be requested directly at UBHT via ICE or using the Bristol Heart Institute standard proforma or at NBT by e-referral. If symptoms are  infrequent and unlikely to be captured by standard ambulatory monitoring then the patient should be advised to attend the practice or A+E during an episode for an ECG.

  • Arrange blood tests to check for an underlying cause - FBC, TFT, UE, HbA1c, LFT, Clotting Screen.

  • Consider a CXR if lung pathology suspected.

  • Consider an echocardiogram if there are concerns about underlying structural heart disease (such as a heart murmur) or functional heart disease (such as heart failure) that will influence their subsequent management (for example choice of antiarrhythmic drug).

Management

  1. Lifestyle modification - controlling lifestyle factors can significantly reduce AF burden. In particular reduction in alcohol intake, blood pressure control, weight loss and moderate exercise.

  2. Anticoagulation - assess stroke risk using CHA2DS2VASc and bleeding risk using HAS-BLED and start anticoagulation treatment if appropriate. Use installed EMIS AF assessment template to assess stroke risk.

  3. Rate control - use a betablocker or rate limiting calcium channel blocker (e.g Diltiazem) to reduce the heart rate if necessary.

  4. Rhythm control - consider referral for cardiology if appropriate. See Referral to Cardiology section below for further advice.

Advice from Local Cardiologists

You may also consider a referral to Cardiology Advice and Guidance service for more individual advice if required.

NICE guidelines

See Clinical Knowledge Summaries for further advice on diagnosis and management.

Referrral Guidance

Refer to a cardiologist for consideration of rhythm-control treatment (cardioversion, drugs or ablation), people :

  • With clear onset of new symptoms of AF (within last 48 hours).

  • Whose AF has a reversible cause (for example a chest infection).

  • Who have heart failure thought to be primarily caused, or worsened, by AF.

  • With atrial flutter who are considered suitable for an ablation strategy to restore sinus rhythm.

  • For whom a rhythm-control strategy would be more suitable based on clinical judgement and ongoing symptoms.

If the onset of arrhythmia is more than 48 hours or uncertain then start rate-control treatment. If referral for consideration for rhythm-control treatment (cardioversion) is thought to be necessary using clinical judgement, cardioversion should be delayed until the person has been maintained on therapeutic anticoagulation for a minimum of 3 weeks

If you require more specific advice about referral for rhythm control, you can access the Cardiology Advice and Guidance Service via e-Referral.

Anticoagulation

Clinical Knowledge Summaries has guidelines on when to prescribe an anticoagulant including links to CHA2DS2VASc and HAS-BLED assessment tools.

Anticoagulation should be offered in all patients with CHA2DS2VASc score or 1 or more (this includes patients with paroxysmal and persistent AF)

Choice of Anticoagulant

Aspirin monotherapy should not be offered as stroke prophylaxis in AF.

NOAC's are increasingly the anticoagulant of choice in patients with non-valvular AF (i.e. AF not related to prosthetic heart valves or severe mitral stenosis - warfarin should be used in these patients). 

Warfarin is still indicated if NOAC's are not indicated or not tolerated.

See the following links for useful advice on the BNSSG formulary website:

Summary of considerations when prescribing a NOAC

Anti-coagulation - leaflet. Patient Information Leaflet.

NOAC decision aid

Warfarin - FAQs

Anticoagulant and antiplatelet co-prescribing information

Other useful resources for reference

Red Flags

Admit or discuss with on call cardiologist if the patient has any of the following:

  • A rapid pulse (greater than 150 beats per minute) and/or low blood pressure (systolic blood pressure less than 90 mmHg).

  • Loss of consciousness, severe dizziness, ongoing chest pain, or increasing breathlessness.

  • A complication of AF, such as stroke, transient ischaemic attack, or acute heart failure.