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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

References

  1. Atrial Fibrillation: diagnosis and management guidance 196 , April 2021 *Atrial fibrillation: diagnosis and management (nice.org.uk)
  2. 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)
  3. Perry MKemmis Betty SDownes NAndrews NMackenzie SAtrial fibrillation: diagnosis and management—summary of NICE guidance doi:10.1136/bmj.n1150

 

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