1. Clinical pathway for people with atrial fibrillation or at risk of atrial fibrillation
Dr Ruth Chambers OBE
LTC Priority Lead, West Midlands Academic Health Science Network and Chair, Stoke-on-Trent CCG

2. Background
In 2015 Cheshire & Merseyside SCN published a pathway initiative for patients with or at risk of atrial fibrillation
The pathway was developed by disease experts and commissioners from across the Cheshire & Merseyside area, supported by the C&M Cardiac Network, funded by Boehringer Ingelheim and led by Stephen Callaghan of EQE Health
The target audience included:
Providers of AF-related services
Primary Care
Patients
Consultants in public health
Public health commissioners
Clinical Commissioning Groups
NHS England
Link to pathway document:
25/02/2016

3. Aims of the pathway
The short and long-term aims of introducing and implementing a pathway for AF across different care settings are based on five fundamental principles: 1 Prevention of AF 2 Early detection of AF 3 Treatment of AF in acute and long-term settings 4 Reduction of complications (e.g. stroke, thrombo-embolic disease and heart failure) 5 Support at the end of life
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4. The Pathway
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5. Prevention of AF Primary prevention:
Maintaining a heart-healthy lifestyle
Treatment of other underlying conditions that can contribute to the onset of AF:
Sleep apnoea
Thyroid disease
Diabetes
Obesity
Chronic lung disease
Other heart conditions
Secondary prevention:
Anticoagulation (in accordance with CHA2 DS2 -VASc)
Regular physical activity
Heart-healthy diet, low in saturated fats, trans fats, and cholesterol
Management of high blood pressure
Avoiding excessive amounts of alcohol and caffeine
Smoking cessation
Cholesterol control and maintaining a healthy weight
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6. First stage - Targeted & opportunistic screening
Purpose of this stage: To identify individuals with atrial fibrillation early in order to initiate treatment and reduce risk of adverse events (stroke or transient ischaemic attack, thromboembolism or heart failure).
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7. Second stage - Identification & assessment of AF
Purpose of this stage: Accurate detection and confirmation of atrial fibrillation and an assessment as to its cause.
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8. Third stage – Initial management
Purpose of this stage: To provide confidence for primary care to manage stable atrial fibrillation (AF) and clarify the place of specialist services.
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9. Fourth stage - Long-term management
Purpose of this stage:
Provide a robust and continuous monitoring system to ensure adequate treatment is given for prevention of strokes in patients who are previously or currently diagnosed with atrial fibrillation.
Continually assess patient symptoms and how they affect their quality of life and allow access to specialist services if required.
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10. Anticoagulation for AF patients
Decision to anticoagulate should be based on their CHA2 DS2 -VASc and HAS-BLED scores
NICE recommends anticoagulation with either a novel oral anticoagulant agent (NOAC) such as direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban), direct thrombin inhibitors (Dabigatran) or Vitamin K antagonist such as warfarin.
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11. 25/02/2016

12. Reference
Cheshire & Merseyside Strategic Clinical Network (2015). Clinical pathway for people with atrial fibrillation or at risk of atrial fibrillation.
25/02/2016