Issue 3 Review Date: June 2013 Page 1 of 2

The aim in all patients is to fully relieve all symptoms and for the stroke risk to be low.

North Wales Cardiac Network Atrial Fibrillation / Atrial Flutter Management Pathway (AF)

New onset Atrial Fibrillation/Atrial Flutter with symptoms <48 hours or

haemodynamically unstable

Acute Medical admission recommended

All chronic disease clinics or clinical suspicion of AF History and examination Manual pulse check If irregular pulse, perform an ECG to confirm Consider Heart Failure diagnosis requiring echo (not BNP) if ECG

has abnormal QRS or T waves but slowly control heart rate first.

Further investigations: TFT, FBC,U&E, glucose, manual BP

Stroke Risk Stratification/thromboprophylaxis for all patients http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11646) or CHA2DS2VASc score (see over)

Permanent Accepted and longstanding

Long standing or persistent Not self terminating, lasting > 7 days

up to 12 months (or more with previous successful cardioversion)

Paroxysmal Recurrent episodes lasting usually <48 hours, max 7

days

Attempt rate control only

Consider rhythm control if <65 years or symptomatic with AF, secondary to a

treated corrected precipitant. Otherwise use rate control

Rhythm control Identify trigger factors

(e.g. alcohol)

Refer for specialist opinion if patient still symptomatic. Likely to be offered: Electrical cardioversion / EPS ablation so need warfarin initiation on referral. Amiodarone (permanent AF) or

Dronedarone (non permanent AF) can be used (short term <6/12) to increase success of ECV. Pharmacological “pill in the pocket” therapy may be useful for paroxysmal events.

Management advice: Start standard ß blocker (bisoporolol or carvedilol) or rate limiting calcium antagonist (Verapamil or Diltiazem) if no LVSD Titrate to achieve resting ventricular rate of <80

b.p.m. or <110b.p.m. on exercise Add digoxin for resting rate control if resting

Management advice: Start standard ß blocker (bisoprolol or carvedilol) or rate limiting calcium antagonist (Verapamil or Diltiazem) if ß blocker not tolerated and no LVSD Planned Electrical Cardioversion – use warfarin 3-4

weeks beforehand and at least 3 weeks after.

Key: Green = Primary Care Red = Secondary Care Yellow = Primary and Secondary Care

Rhwydwaith Cardiaidd Gogledd Cymru North Wales Cardiac Network

Pharmacological cardioversion Electrical cardioversion Ablation for flutter

Issue 3 Review Date: June 2013 Page 2 of 2

Who needs Warfarin? Usually those with at least 1 other risk factor for stroke. Annual risk of stroke is 1% per annum in the young and fit (5% over 5 years), increasing with age

and other risk factors for all types of atrial fibrillation and flutter.

The following links assist in the assessment of risk/benefit of warfarin treatment:

http://nntonline.net

Risk factors for stroke in non-valvular AF

Major risk factors Previous stroke TIA or systemic embolism Age ≥ 75 years

Clinically relevant non-major risk factors

CHF or moderate to severe LV systolic dysfunction (e.g. LV EF ≤ 40%) Hypertension Diabetes mellitus Age 65-74 years Female sex Vascular disease

Risk factor-based point-based scoring system – CHA2DS2-VASc

Risk Factor Score

Congestive heart failure/LV dysfunction 1 Hypertension 1 Age ≥ 75 years 2 Diabetes mellitus 1 Stroke/TIA/thrombo-embolism 2 Vascular disease 1 Age 65-74 years 1 Sex category (i.e. female sex) 1 Maximum score 9

Adjusted stroke rate according to CHA2DS2-VASc

CHA2DS2-VASc score

Patients (n = 7329)

Adjusted stroke rate (%/y)

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%

Clinical characteristics comprising the HAS-BLED bleeding risk score; if >3, need strict control of INR

Letter Clinical characteristic Points

awarded H Hypertension 1 A Abnormal renal and liver function ( 1

point each) 1 or 2

S Stroke 1 B Bleeding 1 L Labile INRs 1 E Elderly (e.g. age > 65 years) 1 D Drugs or alcohol (1 point each) 1 or 2

Maximum 9 points

Patients with mitral stenosis, prosthetic heart valves or risk score >1 usually require warfarin. Where antithrombotic therapy is given:

The most effective treatment (reduces stroke risk by 2/3), is adjusted-dose Warfarin (target INR 2.5, range 2.0 to 3.0). USE WHOLE mg DOSES.

Where Warfarin is not indicated, give aspirin 75 to 300 mg/day +/- clopidogrel 75mg daily (both reduce stroke risk additively by 1/5 each). Consider gastroprotection.

If Warfarin is appropriate, do not co administer aspirin purely for thromboprophylaxis, as it provides no additional benefit. Aspirin may be continued if clearly indicated separately.

Clopidogrel has a similar benefit to Aspirin but increases the bleeding risk when used concurrently. Initiation of Warfarin:

There is no need to achieve anticoagulation rapidly; a slow loading regimen is safe and achieves therapeutic coagulation in the majority of people within 3-4 weeks.

Ensure appropriate monitoring of INR using clinical support software. See BNF for potential drug interactions.

Atrial Flutter: Rate and rhythm control can be more difficult DC cardioversion and / or ablation are more successful so earlier referral is indicated.

North Wales Cardiac Network 2011

Atrial Fibrillation / Atrial Flutter Management Pathway (AF)