Presentation on theme: "New Atrial Fibrillation/Flutter Pathway and GRASP Tool"— Presentation transcript:
1 New Atrial Fibrillation/Flutter Pathway and GRASP Tool Kay ElliottBritish Heart Foundation Arrhythmia Nurse SpecialistDorset County Hospital NHS Foundation Trust
2 AimTo Discuss:Primary/Secondary Care Pathway for new onset atrial fibrillation/FlutterGRASP* Tool – Identifying and risk stratifying chronic AF/Flutter in primary care*Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation in Patients in Primary Care
3 New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell?YesNoPrimary CareSTART WARFARIN AND RATE CONTROL (see box A)Issue patient education leaflet:‘Atrial Fibrillation and Warfarin’. Attached, also available:Admit to HospitalNEED FURTHER ADVICE?CONTACT:BHF ARRHTYHMIA NURSE:Box A: Rate controlFirst Line:1. Beta-blocker (e.g. Bisoprolol) or a rate limiting calcium antagonist (e.g. Diltiazem), if beta-blocker contraindicated2. Digoxin – additional to optimise rate control, where required. As monotherapy only in predominantly sedentary patients.NICE (2006)PersistentFax referral to Rapid Access Atrial Fibrillation/FlutterClinic.(Form attached. Also available on Dorset County Hospital intranet or by contacting BHF Arrhythmia Nurse)ParoxysmalRefer to cardiology team in the usual way.If acutely unwell – admitIdentify asymptomatic AF by including opportunistic pulse check at routine appointmentsDecision to start warfarin – on risk NICE STRATIFICATION OR CHAD2 SCORE – SAME ISSUE FOR REGARDLESS OF PAROXYSMAL OR PERSISTENT – YOUNGER PATIENTS WITH LOWER RISK IF LIKELY TO NEED DCCV MAY NEED TO START WARFARIN TO AVOID DELAY.RATE CONTOL FOR SYMPTOM CONTROLTELEPHONE CONTACT IF UNSURE/NEEDING ADVICEPAROXYSMAL – CONSULTANT PERSISTENT – RAPID ACCESS AF/FLUTTER CLINIC Rapid Access Atrial Fibrillation/Flutter ClinicCardiologist
4 Atrial Fibrillation/Flutter Clinic Rapid AccessAtrial Fibrillation/Flutter ClinicONE STOP APPOINTMENT(WITHIN 4 WEEKS OF REFERRAL)ECHO AND ECGBHF ARRHYTHMIA NURSE CLINIC:q Review history, symptoms, test and examination resultsq Patient educationq Agree treatment plan: DC Cardioversion or Rate Controlq Arrange ongoing follow-up, where requiredCardiologist input into RAAF clinic. Also patients referred for DC Cardioversion from cardiology clinic or in-patient stay.CardiologistBHF Arrhythmia Nurse Specialist:Arrange DC CardioversionPrimary CareManage long-term warfarin and rate-control
5 DC Cardioversion – BHF ARRHYTHMIA NURSE/DAY SURGERY UNIT Prepare for DC Cardioversion:Weekly INR (Target ), must have INR >2.0 for four full weeks prior to DC Cardioversion (see next page)DC Cardioversion – BHF ARRHYTHMIA NURSE/DAY SURGERY UNITProcedureReview of medications and treatment pre-discharge(Cardiology Specialist Registrar and BHF Arrhythmia Nurse)Review with BHF Arrhythmia Nurse at 4 weeks, ongoing treatment planN.B. Maintaining a therapeutic INR during the four weeks post successful DC Cardioversion is important in terms of stroke risk reduction.
6 4 Weeks post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse Is the Patient in Sinus Rhythm?Yes/NoYESNOCardiology ReviewPatient remains symptomatic despite adequate rhythm or rate control.Other cardiac complications are revealed.Depending on clinical indicationsand patient preference either:Re-attempt DC Cardioversion with amiodarone coverRefer for ablation therapyRate control/Warfarin (primary Care)Refer to Electrophysiologycentre for ablation therapy, if appropriate6 months post procedure Follow-Up (NICE, 2006)BHF Arrhythmia NurseIs the Patient in Sinus Rhythm?
7 6 months post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse Is the Patient in Sinus Rhythm?YesNoDepending on clinical indications and patient preference either:Re-attempt DC Cardioversion with amiodarone coverReferral for ablation therapyRate control/Warfarin (primary Care)Discharged to primary care and advised to seek medical attention if symptoms recur
8 Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF) Prevalence of AF in primary care is 1.2% (England)12,500 strokes per year are thought to be directly attributable to AFEstimated annual cost of maintaining one patient on warfarin: £383Estimated cost per stroke due to AF is £11,900 in the first year post stroke occurrence
9 Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF) NICE estimate that 46% of patients thatshould be on warfarin are not receiving itWarfarin reduces risk of stroke by 64% in atrial fibrillationAspirin reduces the risk of stroke by 22% in atrial fibrillation
10 Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF) The GRASP-AF Tool facilitates audit to identify high risk AF patients not on warfarinIt is a MIQUEST IT tool that can be freely downloaded from
11 Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF) It can be used to identify patients in atrial fibrillation with a CHADS2 score of >1The final report can exclude those with recorded contraindications to warfarin
12 Summary Identify new atrial fibrillation/flutter – (include routine pulse checks at all appropriate consultations)Refer to RAAF clinic (persistent), consultant (paroxysmal) or admit if acutely unwellRate Control and warfarin/aspirin in primary carePatients will be reviewed with echocardiogram andspecialist clinic/consultant inputGRASP-AF Tool – opportunity to ensure practicepopulation on evidence based stroke prophylaxisin atrial fibrillation – Potential to reduce morbidity/mortality and health costs