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New Atrial Fibrillation/Flutter Pathway and GRASP Tool

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Presentation on theme: "New Atrial Fibrillation/Flutter Pathway and GRASP Tool"— Presentation transcript:

1 New Atrial Fibrillation/Flutter Pathway and GRASP Tool
Kay Elliott British Heart Foundation Arrhythmia Nurse Specialist Dorset County Hospital NHS Foundation Trust

2 Aim To Discuss: Primary/Secondary Care Pathway for new onset atrial fibrillation/Flutter GRASP* 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? Yes No Primary Care START WARFARIN AND RATE CONTROL (see box A) Issue patient education leaflet: ‘Atrial Fibrillation and Warfarin’. Attached, also available: Admit to Hospital NEED FURTHER ADVICE? CONTACT: BHF ARRHTYHMIA NURSE: Box A: Rate control First Line: 1. Beta-blocker (e.g. Bisoprolol) or a rate limiting calcium antagonist (e.g. Diltiazem), if beta-blocker contraindicated 2. Digoxin – additional to optimise rate control, where required. As monotherapy only in predominantly sedentary patients. NICE (2006) Persistent Fax referral to Rapid Access Atrial Fibrillation/Flutter Clinic. (Form attached. Also available on Dorset County Hospital intranet or by contacting BHF Arrhythmia Nurse) Paroxysmal Refer to cardiology team in the usual way. If acutely unwell – admit Identify asymptomatic AF by including opportunistic pulse check at routine appointments Decision 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 CONTROL TELEPHONE CONTACT IF UNSURE/NEEDING ADVICE PAROXYSMAL – CONSULTANT PERSISTENT – RAPID ACCESS AF/FLUTTER CLINIC  Rapid Access Atrial Fibrillation/Flutter Clinic Cardiologist

4 Atrial Fibrillation/Flutter Clinic
Rapid Access Atrial Fibrillation/Flutter Clinic ONE STOP APPOINTMENT (WITHIN 4 WEEKS OF REFERRAL) ECHO AND ECG BHF ARRHYTHMIA NURSE CLINIC: q       Review history, symptoms, test and examination results q       Patient education q       Agree treatment plan: DC Cardioversion or Rate Control q       Arrange ongoing follow-up, where required Cardiologist input into RAAF clinic. Also patients referred for DC Cardioversion from cardiology clinic or in-patient stay. Cardiologist BHF Arrhythmia Nurse Specialist: Arrange DC Cardioversion Primary Care Manage 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 UNIT Procedure Review of medications and treatment pre-discharge (Cardiology Specialist Registrar and BHF Arrhythmia Nurse) Review with BHF Arrhythmia Nurse at 4 weeks, ongoing treatment plan N.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/No YES NO Cardiology Review Patient remains symptomatic despite adequate rhythm or rate control. Other cardiac complications are revealed. Depending on clinical indications and patient preference either: Re-attempt DC Cardioversion with amiodarone cover Refer for ablation therapy Rate control/Warfarin (primary Care) Refer to Electrophysiology centre for ablation therapy, if appropriate 6 months post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse Is the Patient in Sinus Rhythm?

7 6 months post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse
Is the Patient in Sinus Rhythm? Yes No Depending on clinical indications and patient preference either: Re-attempt DC Cardioversion with amiodarone cover Referral for ablation therapy Rate 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 AF Estimated annual cost of maintaining one patient on warfarin: £383 Estimated 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 that should be on warfarin are not receiving it Warfarin reduces risk of stroke by 64% in atrial fibrillation Aspirin 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 warfarin It 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 >1 The 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 unwell Rate Control and warfarin/aspirin in primary care Patients will be reviewed with echocardiogram and specialist clinic/consultant input GRASP-AF Tool – opportunity to ensure practice population on evidence based stroke prophylaxis in atrial fibrillation – Potential to reduce morbidity/mortality and health costs

13 Over to You – Any Questions?


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