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

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Presentation on theme: "New Atrial Fibrillation/Flutter Pathway and GRASP Tool Kay Elliott Arrhythmia Nurse Specialist Dorset County Hospital NHS Foundation Trust."— Presentation transcript:

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

2 New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell? No Admit to hospital Rate or Rhythm control strategy initiated and discharged back to primary care with follow- up/onward referrals if required. Patients requiring DC Cardioversion referred to AF/Flutter Clinic See next slide NEW ONSET ATRIAL FIBRILLATION/FLUTTER Yes

3 Primary Care Initiate appropriate stroke/TIA prophylaxis according to CHA  DS  –VASc score (BOX A) and Initiate appropriate rate control (BOX B) BOX A: CHA  DS  –VASc Scoring Risk FactorPoint Heart Failure/LV Dysfunction 1 Hypertension 1 Aged > 75 2 Diabetes mellitus 1 Stroke / TIA 2 Vascular disease 1 Age Female 1 CHA  DS  –VASc Result: 0 = Aspirin 75mg – 325mg daily or no antithrombotic therapy (preference for no therapy) 1 = Either OAC or aspirin (preference for OAC rather than aspirin) > 2 = OAC recommended Box B: Rate control First Line: Beta-blocker (e.g. Bisoprolol) or a rate limiting calcium antagonist (e.g. Diltiazem), if beta-blocker contraindicated Second Line: Digoxin – additional to optimise rate control, where required. As monotherapy only in predominantly sedentary patients.

4 Paroxysmal Persistent NEED FURTHER ADVICE? ARRHYTHMIA NURSE: Fax Dorset County Hospital intranet or by contacting BHF Arrhythmia Nurse) referral to Rapid Access Atrial Fibrillation/Flutter Clinic. (Form attached. Also available on the intranet Rapid Access Atrial Fibrillation/Flutter Clinic ECHO AND ECG BHF ARRHYTHMIA NURSE CLINIC: Review history, symptoms, test and examination results Patient education Agree treatment plan: Rhythm or Rate control Arrange ongoing follow-up, where required Referral to cardiology clinic if other cardiac issues identified Refer to cardiology team: referral letter or choose and book Cardiologist Appropriate strategy initiated with onward plan/referrals made. Patients requiring DC Cardioversion referred to AF/Flutter Clinic

5 Rhythm Control Rate Control  Arrhythmia Nurse Specialist; arrange DC Cardioversion and/or, if indicated:  Refer to electrophysiology centre for ablation Manage long-term warfarin and rate-control – Primary Care

6 Prepare for DC Cardioversion: Weekly INR (Target ), must have INR >2.0 for four full weeks prior to DC Cardioversion DC Cardioversion – DAY SURGERY UNIT Procedure and review of medications/onward management plan (Arrhythmia Nurse and Cardiology Specialist Registrar) pre discharge 4 Weeks post procedure: Follow-Up with Arrhythmia Nurse Is the Patient in Sinus Rhythm and are their symptoms improved/satisfactory? No Depending on clinical indications and patient preference either: Re-attempt DC Cardioversion with additional AA cover (amiodarone) Refer for ablation Rate control/Warfarin - (primary Care) Refer to Cardiologist if patient has ongoing symptoms or complications Yes 6 Months post procedure: Follow-Up with Arrhythmia Nurse Is the Patient in Sinus Rhythm and are their symptoms improved/satisfactory? Cont...

7 6 Months post procedure: Follow-Up with Arrhythmia Nurse Is the Patient in Sinus Rhythm and are their symptoms improved/satisfactory? YesNo Discharge to primary care and patient advised to seek medical attention if symptoms recur Depending on clinical indications and patient preference either: Re-attempt DC Cardioversion with additional AA cover (amiodarone) Refer for ablation Rate control/Warfarin - (primary Care) Refer to Cardiologist if patient has ongoing symptoms or complications Anti-coagulation post DC Cardioversion: Maintaining a therapeutic INR during the four weeks post DC Cardioversion is essential for All patients regardless of their CHA  DS  –VASc score. Advice with regards to long-term anti-coagulation is based on patients’ CHA  DS  –VASc score rather than the presence of sinus rhythm/absence of atrial fibrillation/flutter on ECG/Holter.

8 Over to You – Any Questions?


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