1.2. Atrial Fibrillation Pathway

Guidelines for the Community Management of Atrial Fibrillation

1. Algorithm

Yes

Suspected AF

(irregular pulse, palpitations)

ECG, FBC, TFT, U&E

Confirms AF?

Consider alternative

diagnosis

Consider underlying causes

Hypertension

CAD

Mitral valve stenosis

Chest infection/COPD

Thyrotoxicosis

Heart failure

Alcohol

Mitral valve stenosis

- refer to consultant

Treat & review

underlying causes

No identifiable cause

No

Yes

Rate Control – beta blocker,

verapamil or digoxin

Is the patient

symptomatic despite

rate control?

Refer to cardiologist

Assess thrombotic risk – CHADS2 score

Start anticoagulation therapy if indicated

Continue to review

regularly to assess

symptoms and

indications for

Refer to cardiologist

Unsure

No

Indications for referral:

Paroxysmal AF

Additional cardiac problems - need a full

cardiological assessment

Additional medical problems

Poor response to therapy

Unable to achieve adequate rate control

Symptoms despite adequate rate control

Recent onset and reversible precipitant

e.g. chest infection, recent cardiac

surgery

Atrial flutter

Heart failure and AF

Echo

CHADS2 Score

Chronic heart failure +1

Hypertension +1

Age 75 or >75 yrs old +1

Diabetes Mellitus +1

Stroke previously or

TIA

+2

Maximum score 6

Cardiovascular Joint Formulary Prescribing Guidance (Version 11)

(Prepared in collaboration with University Hospitals Birmingham Cardiovascular Consultants and GP Clinical Leads)

Prescribing

Digoxin Usual dose 250 mcg OD (do not exceed) Reduce dose to 125 mcg OD if < 60 Kg, > 75 yrs

or if renal function impaired Use 62.5 mcg od for the very elderly or severe

renal dysfunction (eGFR<30) If rapid response needed, load with 500 mcg +

500 mcg 12 hours apart. Beta Blockers – Use Bisoprolol Start at 2.5 mg OD Titrate up weekly to 5, 7.5 or 10 mg to obtain

radial rate of 70/min

Verapamil Use a SR preparation 120 mg or 240 mg od.

Titrate according to radial pulse as above Can be used in combination with 125mcg digoxin

but not beta blockers.

Treatment Strategy Decision Tree

Patients unsuitable for rhythm control strategies include those with: contraindications to anticoagulation; structural

heart disease (e.g. large left atrium >5.5 cm, mitral stenosis) that precludes long-term maintenance of sinus rhythm; a

long duration of AF (usually >24 months); and/or relapses, even with concomitant use of anti-arrhythmic drugs or

non-pharmacological approaches; an ongoing but reversible cause of AF (e.g.thyrotoxicosis).

Asymptomatic

Symptomatic

Confirmed diagnosis of AF

Further investigations including ECHO and clinical assessment including

risk stratification for stroke/thromboembolism

Paroxysmal AF Non-Paroxysmal AF

Rhythm-control

Refer to

electrphysiologist

Rate-control

Try rhythm-control first for patients with persistent AF:

who are symptomatic

who are younger

presenting for the first time with lone AF

secondary to a treated or corrected precipitant with

congestive heart failure

Try rate-control first for patients with persistent AF:

Who have a LA size >5.5cm

Have had persistent atrial fibrillation for more

than 2 years

unsuitable for cardioversion

unsuitable for anticoagulation

Remains symptomatic

Refer to

Electrophysiologist

Assessing the Risk of Stroke in Atrial Fibrillation

A patie t s isk of th o oe oli e e ts should e assessed usi g eithe the CHADS2 score or the CHA2DS2-VASc

score. In general patients with a CHADS2 score of 1 or CHA2DS2-VASc score of 2 or above should be anticoagulated

unless there is a contraindication to warfarin (e.g. HAS-BLED score of 3 or above). Patients with a CHA2DS2-VASc

score of 1 may also benefit from anticoagulation.

Patients with a CHADS2 score of 2 or above (or a CHA2DS2-VASc score of 3 or above) with a contraindication for

warfarin or a HAS-BLED of 3 or above should be referred to an electrophysiologist for consideration of

anticoagulation or alternatives. In general there is little role for aspirin as thrombophrophylaxis, although it may be a

less good alternative to warfarin in low risk patients (CHADS2 score of 1 or CHA2DS2-VASc score of 2) or as standalone

therapy in Lone AF (CHADS2 score of 0).

CHADS2 Score

CHA2DS2-VASc: The table indicates the CHA2DS2-VASc scores and related stroke risk and risk levels:

CHADS2 score Stroke risk per 100

patients per year

CHADS2 risk level Warfarin

recommended

0 1.9 Low No

1 2.8 Low No

2 4.0 Moderate Yes

3 5.9 Moderate Yes

4 8.5 High Yes

5 12.5 High Yes

6 18.2 High Yes

Chronic heart failure +1

Hypertension +1

Age 75 or >75 yrs old +1

Diabetes Mellitus +1

Stroke previously or TIA +2

Maximum score 6

CHA2DS2-VASc

score

Patients

(n=7329)

Adjusted stroke

rate (%/year)

0 1 0%

1 422 1.3%

2 1230 2.2%

3 1730 3.2%

4 1718 4.0%

5 1159 6.7%

6 679 9.8%

7 294 9.6%

8 82 6.7%

9 14 15.2%

Congestive heart failure/LV dysfunction +1

Hypertension +1

Age >75 years +2

Diabetes Mellitus +1

Stroke/TIA/Thrombo-embolism previously +2

Vascular disease +1

Age 65-74 +1

Sex category (i.e. female sex) +1

Maximum Score 9

1.3. Heart Failure Pathway

Diagnosing Heart Failure

Take detailed history and perform a clinical examination

Previous MI No previous MI

GP suspects Heart Failure

O tai lood sa ple i ed top tu e & e uest BNP test i Othe o io he ist y e uest fo

Send specimen to secondary care lab on the same day

(DO NOT STORE OVERNIGHT)

High levels Raised levels

Specialist assessment &

Doppler echocardiography

Within 2

weeks

Abnormality consistent with

Heart Failure

No clear abnormality Normal Levels

Consider measuring natriuretic

peptides if levels not known

Assess severity, aetiology, precipitating factors, type of cardiac dysfunction,

correctable causes Raised levels

Investigate other

diagnoses Other cardiac

abnormality

Heart Failure due to left

ventricular systolic

dysfunction

Heart Failure with

preserved ejection

fraction Heart Failure unlikely,

other diagnosis

Within 2

weeks

Within 6 weeks

Serum Natriuretic Peptides

High levels – BNP >400pg/ml (116pmol/litre) or NTproBNP >2000pg/ml (236 pmol/litre)

Raised levels – BNP 100-400 pg/ml (29-116 pmol/litre) or NTproBNP 400- 2000 pg/ml (47-236

pmol/litre)

Normal levels – BNP <100pg/ml (29 pmol/litre) or NTproBNP <400 pg/ml (47 pmol/litre)

Heart Function Centre

One-Stop Heart Failure Clinic

All patients referred to the One-Stop Heart Failure Clinic will undergo echocardiography, ECG and will be assessed by a

Cardiologist. There is no access to echocardiography unless there is a suspicion of heart failure. Suspected valve disease and

dysrrhythmias (including AF) without suspected heart failure should be referred to other Cardiology clinics.

Preferred

clinic

All Saints Medical Centre

Woodgate Valley

QEH/Selly Oak

Patient Details

Surname Sex

Forename Date of birth

Address NHS Number Occupation

Ethnic origin

Postcode First Language

Telephone Need an interpreter?

GP Details

Name Telephone Address

Date of referral

Postcode

Strict referral criteria – tick appropriate box

History and clinical signs *

Clinical suspicion of heart failure

and □ History of MI Clinical suspicion of heart failure

No history of MI □ High NT pro-BNP *

* ≥400 ng/L NT pro-BNP level:………………………

Urgent referral? Yes □ No □

* ECG and CXR would be useful, but not essential for referral.

If cardiovascular conditions other than heart failure are detected, would you consent for the patient to be assessed

and treated at the Queen Elizabeth Hospital? Yes □ No □

Has the patient previously attended this clinic? Yes □ No □

Fax to: 0121 460 5806 Email to: heart.failure@uhb.nhs.uk

OUTPATIENT MANAGEMENT OF HEART FAILURE

SYSTOLIC HEART FAILURE

NYHA I NYHA II NYHA III

NYHA IV

No SOB/fatigue Ordinary activity causes SOB/fatigue

Less than ordinary activity causes SOB/fatigue

SOB/fatigue at rest

Drug therapy

Loop diuretic if oedema

Loop diuretic if oedema

Loop diuretic if oedema

Loop diuretic if oedema

ACE inhibitor /ARB ACE inhibitor /ARB ACE inhibitor /ARB ACE inhibitor /ARB

Beta-blocker Beta-blocker Beta-blocker Beta-blocker

Digoxin Digoxin

Aldosterone antagonist Aldosterone antagonist

Device therapy

Consider ICD Consider ICD Consider ICD Consider ICD

Consider CRT Consider CRT

MEDICAL THERAPY Loop diuretics: For all patients. Commence if peripheral oedema present. Estimate fluid excess in litres. Aim for weight loss of 0.5 kg/day to achieve dry weight. Prescribe loop diuretics without amiloride if on ACE inhibitor. ACE inhibitors and/or ARBs: Either for all patients and combination in NYHA class III and IV. Start at a low dose and uptitrated every 2 weeks to

reach maximum tolerated dose. Measure U + Es at each dose increment. Ensure creatinine does not rise by >20 mol/l and no hypotensive

symptoms. HIGH RISK of first-dose hypotension if: Na <130 mmol/l, systolic BP <100 mmHg, creatinine >200 mol/l, taking > furosemide-equivalent dose of 80 mg/day. If at high risk, refer to HEART FAILURE SERVICE.

*, unlicensed dose, but lower doses not effective

Beta-blockers: Commence once stable on ACE inhibitors and: 1) Free of pulmonary and peripheral oedema; 2) pulse >50 bpm, SBP>90 mmHg. COPD without reversibility is not a contraindication to beta-blockers.

Aldosterone antagonists: For NYHA class III and IV. Start only after referral to HEART FAILURE SERVICE. Close monitoring of U + Es required, ensuring serum K <5.5 mmol/L. Use spironolactone in chronic heart failure. Use eplerenone if gynaecomastia with spironolactone and if an acute MI is followed by symptoms / signs of heart failure and LVSD.

Digoxin: For class III and IV. digoxin 250 g od, or 125 g od if >70 yrs or if renal impairment. Levels not required unless toxicity suspected.

Hydralazine and nitrates: For patients who are intolerant to ACE inhibitors / ARBs.

LICENSED DRUG

INITIAL DOSE

TARGET DOSE

Ramipril * 2.5 mg od 10 mg od

Perindopril 2 mg od 8 mg od

Candersartan 4 mg od 32 mg od

Losartan 25 mg od 150 mg od *

LICENSED DRUG INITIAL DOSE TARGET DOSE

Bisoprolol 1.25 mg od 10 mg od

Carvedilol 3.125 mg bd 50 mg bd

Nebivolol 1.25 10 mg od

LICENSED DRUG INITIAL DOSE TARGET DOSE

Spironolactone 12.5 mg od 50 mg od

Eplerenone 12.5 mg od 50 mg od

Exercise rehabilitation: For all patients. Refer to rehabilitation programme.

If patient improves in NYHA class, do not change drugs, except loop diuretics according to oedema

DEVICE THERAPY Once optimised on medical therapy, ensure all patients have been considered for device therapy:

CRT-P ICD CRT-D

NYVA class III-IV Previous VT or VF with syncope or cardiac arrest VT without syncope or cardiac arrest, plus LVEF<35%

Patients qualifying for CRT-P and ICD

QRS ≥150ms or 120-149 plus dyssynchrony

Previous MI, LVEF<35% and: Non-sustained VT on Holter plus inducible VT on EP testing

LVEF<35% Previous MI, LVEF<30%, QRS ≥120 ms

Optimal medical therapy A familial cardiac condition with a high risk of suddendeath

HEART FAILURE WITH NORMAL EJECTION FRACTION (‘DIASTOLIC’ HEART FAILURE)

Treatment will mainly consist of loop diuretics and antihypertensive treatment. Specialist input required. LONG TERM MONITORING All patients who are optimised on above drugs / device therapy should be monitored at least 6-monthly, to include:

NYHA class, fluid status (oedema), rhythm, U + Es Review of medication and eligibility for devices (see above)

NICE guidelines 2010

TREATMENT ALGORITHM

heart.failure@uhb.nhs.uk

1.4. Calcium Scoring for Stable Chest Pain (UHBfT)

This service is for patients with recent intermittent cardiac chest pain or discomfort suspected to be stable angina,

who require assessment and investigation.

The service provides an alternative pathway for patients who may previously have been referred to the Rapid Access

Chest Pain Clinic but on assessment, have an estimated coronary artery disease (CAD) score of 10-29%, resulting in

them being eligible for direct access to calcium scoring.

Potentially, this helps to streamline the current pathway by reducing the number of patients who are seen in the

Rapid Access Chest Pain Service and then referred onto a consultant cardiology specialist for further assessment.

Appendix 1 provides details of the referral form and pathway into the service

Appendix 1

2. Direct Access Diagnostics

2.1. Direct Access Echo for Atrial Fibrillation

Patients who require an echo to confirm a diagnosis of AF can be referred into the direct access

service at UHBfT using the referral form outlined below. The service can be accessed via a faxed

referral or through choose and book.

Key performance indicators for the service include:

95% of all referred patients seen for a direct access echo within 4 weeks of the referral being made

95% of all tests epo ted to the patie t s GP within 3 working days

95% of all reports coming back to GPs through the electronic links system or fax

CARDIOLOGY REFERRAL

URGENCY OF REFERRAL

Routine Semi Urgent

SPECIALITY REFERRAL

General Electrophysiology Valve Diagnostics Intervention Heart Failure GUCH

INVESTIGATIONS REQUIRED (please tick as appropriate)

Resting ECG 24/48/72 Hour ECG Monitoring 7 Day ECG Monitoring 24 Hour BP Monitoring Echocardiogram for Atrial Fibrillation Has new onset of AF been confirmed by ECG?

Echocardiogram for Heart Failure Please note that this can only be requested after an elavated BNP test or previous MI

No Consultation Required

Please tick box and fax form to: 0121 460 5833

Consultation Required

Please tick box and fax form to: 0121 460 5833

CLINICAL INFORMATION (must be completed)

Reason for Referral (please include provisional

diagnosis)

Stable Chest Pain

Heart Failure

Murmur

Hypertension

Syncope

Palpitations Othe

Symptoms, Duration & Severity

(include impact on quality of life

Blood Test Results (please attach)

FBC U&E LFTs Lipids

Relevant Medical History and Examination Findings

Weight: ......................kg Ht: ..........................cm BMI:..............................

Alcohol: Yes No Blood Pressure: ............mmhg ECG attached: Yes No

Coronary Artery Disease Risk Factors

Family History

Hypertension

Hyperlipidemia

Diabetes

Smoker (in last 10 years

Allergies Nil Known Allergies

Current Medications (attach list if necessary)

See attached list Not on any medications

Special Home Circumstances (Carer, Nursing Home etc)

Version 1 20/11/2

2.2. Direct Access 24 Hour ECG

PATIENT DETAILS

Name: .......................................................... Sex: M F

DOB: ................................................. NHS No: ..................................

Address: ...............................................................................................

Postcode: .......................... Tel No: ............................... (Mandatory)

Hospital Number: .............................................................

1st Language: ........................... Interpreter Required? Y N

GP Name: ............................................................................... Practice: ................................................................ Address/Stamp Tel No: ................................. Fax: .................................... E-mail: .............................................................................. Date of Referral: ...............................................................

Patients who a 24 ECG can be referred into the direct access service at UHBfT using the referral form

outlined in appendix 1. The service can be accessed via a faxed referral or through choose and book.

Key performance indicators for the service include:

95% of all referred patients seen for a direct access echo within 4 weeks of the referral being made

95% of all tests epo ted to the patie t s GP ithi 3 o ki g days

95% of all reports coming back to GPs through the electronic links system or fax

24 Hour Ambulatory ECG Monitoring

Daily Symptoms

(>1 episode per day)

Please refer to inclusion criteria at the

side of the pathway

Refer patient to direct access

service

24 Hour Ambulatory ECG

Had typical symptoms during

Ambulatory Recording?

Yes No

No further investigation

required

GP to reassure patient, monitor

and provide advice on lifestyle,

caffeine and alcohol. Consider

drug therapy

Service Inclusion Criteria

Suspected ectopics of >

2 months duration

Suspected tachycardia

or bradycardia

Service Exclusion Criteria

Known structural or

valvular heart disease

Known coronary artery

disease

Known previous

documented

arrhythmia

Syncope or pre-

syncope

Abnormal 12 lead ECG

Key Performance

Indicators for the

Service

95% of direct access 24 hour ECG referrals seen within 4 weeks of referral being made

95% of direct access 24 hour ECG reports returned to practices via fax or electronic links

95% of direct access 24 hour ECG reports returned to referring GP within 3 working days

Clinically significant arrhythmia

or other abnormal findings?

Yes

Cardiology Consultant

Consultant Opinion

No

Send letter to GP

recommending patient

reassurance and provide

information leaflet

GP

Reassure Patient and

Provide Information Leaflet

2.3. Direct Access BNP Testing for Heart Failure

Diagnosing Heart Failure

Heart Function Centre

Take detailed history and perform a clinical examination

Previous MI No previous MI

GP suspects Heart Failure

O tai lood sa ple i ed top tu e & e uest BNP test i Othe o biochemistry request form

Send specimen to secondary care lab on the same day

(DO NOT STORE OVERNIGHT)

High levels Raised levels

Specialist assessment &

Doppler echocardiography

Within 2

weeks

Abnormality consistent with

Heart Failure

No clear abnormality Normal Levels

Consider measuring natriuretic

peptides if levels not known

Assess severity, aetiology, precipitating factors, type of cardiac dysfunction,

correctable causes Raised levels

Investigate other

diagnoses Other cardiac

abnormality

Heart Failure due to left

ventricular systolic

dysfunction

Heart Failure with

preserved ejection

fraction Heart Failure unlikely,

other diagnosis

Within 2

weeks

Within 6 weeks

Serum Natriuretic Peptides

High levels – BNP >400pg/ml (116pmol/litre) or NTproBNP >2000pg/ml (236 pmol/litre)

Raised levels – BNP 100-400 pg/ml (29-116 pmol/litre) or NTproBNP 400- 2000 pg/ml (47-236

pmol/litre)

Normal levels – BNP <100pg/ml (29 pmol/litre) or NTproBNP <400 pg/ml (47 pmol/litre)

One-Stop Heart Failure Clinic

All patients referred to the One-Stop Heart Failure Clinic will undergo echocardiography, ECG and will be assessed by a

Cardiologist. There is no access to echocardiography unless there is a suspicion of heart failure. Suspected valve disease and

dysrrhythmias (including AF) without suspected heart failure should be referred to other Cardiology clinics.

Preferred

clinic

All Saints Medical Centre

Woodgate Valley

QEH/Selly Oak

Patient Details

Surname Sex Forename Date of birth

Address NHS Number Occupation

Ethnic origin

Postcode First Language

Telephone Need an interpreter?

GP Details

Name Telephone

Address

Date of referral

Postcode

Strict referral criteria – tick appropriate box

History and clinical signs *

Clinical suspicion of heart failure

and □ History of MI

Clinical suspicion of heart failure No history of MI □ High NT pro-BNP *

* ≥400 ng/L NT pro-BNP level:………………………

Urgent referral? Yes □ No □

* ECG and CXR would be useful, but not essential for referral.

If cardiovascular conditions other than heart failure are detected, would you consent for the patient to be assessed

and treated at the Queen Elizabeth Hospital? Yes □ No □

Has the patient previously attended this clinic? Yes □ No □

Fax to: 0121 460 5806 Email to: heart.failure@uhb.nhs.uk