Atrial fibrillation – NICE guidance April 2021
If you suspect AF perform a manual palpation of pulse- this includes people presenting with breathlessness palpitations syncope or dizziness chest dicomfort stroke or TIA
If irregular pulse is felt arrange a 12 lead ECG in all ( with or without symptoms ) If paroxysmal AF is suspected and it is not detected by a 12 lead ECG consider use of ( PF are episodes of AF that stop within 7 days , usually within 48 hrs without any treatment ) ○ 24 hr ambulatory ECG if asymptomatic episodes are suspected or symptomatic episodes are < 24 hrs apart ○ for longer duration NICE suggests ambulatory ECG monitor , event recorder or other ECG technology ( this would be undertaken usually by specialist cardiology team ) Wearable and other devices -the committee has acknowledged that there is some evidence that some new devices were accurate and and showed promise
CHA2DS2VASC Score AF which is symptomatic or asymptomatic , persistent or permanent atrial flutter people at risk of arrhythmia recurrence after cardioversion back to SR or catheter ablation A score of 2 or more is considered as the ideal threshold for anticoagulation. The committee also felt that men with a CHA2D.. score of 1 are at intermediate risk – a group in whom anticoagulation should be considered
NICE recommends using the ORBIT bleeding risk score when you are considering starting AC in people with AF and reviewing people who are already taking anticoagulation Offer monitoring and support to modify risk factors for bleeding as uncontrolled hypertension for those on warfarin poor control of INR review use of concurrent medications as antiplatelets , SSRI’s and NSAID’s advice about harmful alcohol consumption any reversible cause of anaemia It is important to understand that the bleeding risk shoudld not be used to make decisions about if you are going yo offer AC or not but the tool should be used to provide an accurate assessment of absolute bleeding risk. Previously recommended tools as HAS-BLED can be used until ORBIT tool is embedded in clinical pathways and electronic systems .
Discuss the results of risk assessment with them taking into account their specific characteristics, co morbidities, individual preferences
Offer a personalised care of package which covers stroke awareness , measures to prevent stroke , rate control , assessment of symptoms for rhythm control – who to contact for advice and / or psychological support if needed.
For most people benefit of AC outweighs the bleeding risk In those with increased risk of bleeding the benefits of anticoagulation does not always outweigh the bleeding risk and monitoring of bleeding risk is important When deciding which agent to use – discuss the risks and benefits , takes into account any contraindications , particularly follow the guidance on dosages in people with renal impairment , reversal agents and monitoring the committee recommends DOAC’s as they are more effective than warfarin in preventing harm in people at risk of stroke
DOAC’s are the 1st line AC take into account bleeding risk Apixaban , dabigatran , edoxaban and rivaroxaban are all recommended options Committee has not made any recommendation which DOAC should be used but mentions that each AC has different risks & benefits that should be considered & discussed
consider anticoagulation consider bleeding risk Apixaban , dabigatran , edoxaban and rivaroxaban are all recommended options
offer a vitamin K antagonist NICE recommends use of CoaguCheck XS system for self monitoring
continue with current medication discuss the option of switching , taking into account for how much time the person’s INR has been in the therapeutic range
do not stroke prevention therapy given that they have a low risk score ie the CHAD.. score is very low equating a score of 0 for men and 1 in women
The committee says that AC therapy should not be refused solely based on patients age or the fact that they are at risk of falls
Not on anticoagulants –Review stroke risk when they are 65 or if they develop any of the following at any age- ie AF + diabetes heart failure peripheral arterial disease coronary artery disease stroke , TIA or systemic thromboembolism
Not on AC due to bleeding risk or other factors Review stroke and bleeding risk annually and document carefully all decisions
On anticoagulant therapy -Review annually need to anticoagulation and the quality of anticoagulation- taking into account MHRA advice on DOACs review atleast annually or more frequently if clinically relevant events occur affecting anticoagulation or bleeding risk
MHRA advice -exercise caution when using DOACS in people ↑↑ risk of bleeding as older people with renal impairment – advice them about signs & symptoms of bleeding and to read PIL in patients with renal impairment monitor renal function & ensure appropriate dosing MHRA informs that that specific DOAC reversal agents are available for dabigatran , apixaban & rivaroxaban.
offer rate control as 1st line Rx strategy except in people as described in the yellow box below use a standard beta blocker ( ie other than sotalol ) or a rate limiting calcium channel blocker as diltiazem or verapamil as initial rate control monotherapy ( based on symptoms ,heart rate , comorbidities and preferences ) ○ your patient does no or very little physical exercise OR ○ other rate limiting drug options cannot be used due to associated co-morbidities NICE recommends use of Digoxin monotherapy for initial rate control in this group.
Monotherapy does not control symptoms – and continuing symptoms are considered to be caused by poor ventricular rate control – consider
Combination therapy with any 2 of the following a beta blocker diltiazem digoxin The committee recommends not to offer amiodarone for long term rate control
Offer rate control as 1st line except in this group AF has a reversible cause they have heart failure which is caused primarily due to AF with new onset AF with atrial flutter where it is possible to undertake ablation and restore sinus rythm in patients where a rhythm control strategy is more suitable based on clinical judgement.
Refer to NICE guidance on chronic heart failure for people with AF and concomitant heart failure
Specialist care -Rhythm control is advised for people with AF where symptoms continue after the HR has been controlled or for whom the heart rate control strategy has been unsuccessful Cardioversion Ablation Transthoracic echo to assess cardiac function Acute AF management.
Stopping anticoagulants -NICE suggests not to stop anticoagulation solely because AF is no longer detectable and to base decisions to stop anticoagulation on a reassessment of stroke and bleeding risk using CHAD2DS2VASc and ORBIT and a discussion of patient preferences
Referral -The guidance states that people should be referred at any stage if treatment fails to control symptoms and in case patient had cardioversion and AF recurs – it should be within 4 weeks after failed treatment or after recurrence of AF following cardioversion
- Atrial Fibrillation: diagnosis and management guidance 196 , April 2021 *Atrial fibrillation: diagnosis and management (nice.org.uk)
- Arrhythmia alliance Diagnosis and management of atrial fibrillation : Key recommendations for primary care NICE AF guideline (NG196) – Key recommendations for primary care.pdf (heartrhythmalliance.org)
- Atrial fibrillation: diagnosis and management—summary of NICE guidance doi:10.1136/bmj.n1150