Presentation on theme: "New Atrial Fibrillation/Flutter Pathway and GRASP Tool"— Presentation transcript:
1New Atrial Fibrillation/Flutter Pathway and GRASP Tool Kay ElliottArrhythmia Nurse SpecialistDorset County Hospital NHS Foundation Trust
2NEW ONSET ATRIAL FIBRILLATION/FLUTTER New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell?YesNoAdmit to hospitalRate 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 ClinicSee next slideAcute breathlessness/chest painHigh risk of deterioration; fast ventricular rate +/- age, co-morbiditiesBradycardia/syncopal episodes
3BOX A: CHADS–VASc Scoring Primary CareInitiate appropriate stroke/TIA prophylaxis according to CHADS–VASc score (BOX A)and Initiate appropriate rate control (BOX B)BOX A: CHADS–VASc ScoringRisk Factor PointHeart Failure/LV Dysfunction 1Hypertension 1Aged >Diabetes mellitus 1Stroke / TIA 2Vascular disease 1AgeFemale 1CHADS–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 recommendedBox B: Rate controlFirst Line:Beta-blocker (e.g. Bisoprolol) or a rate limitingcalcium antagonist (e.g. Diltiazem), if beta-blockercontraindicatedSecond Line:Digoxin – additional to optimise rate control, whererequired. As monotherapy only in predominantlysedentary patients.NEED FOR CLOSER MONITORING RATE CONTROL, INITIATION OF WARFARIN CONTROLIF CHADS2 = 2 OR ABOVE NO NEED TO DO CHADSVASCC – heart failureH – hypertensionA - > 75 yearsD – DiabetesS – Stroke/TIA – 2 points
4(Form attached. Also available on the intranet ParoxysmalNEED FURTHER ADVICE?ARRHYTHMIA NURSE:PersistentFax Dorset County Hospital intranet or by contacting BHF Arrhythmia Nurse) referral to Rapid Access Atrial Fibrillation/Flutter Clinic.(Form attached. Also available on the intranetRefer to cardiology team: referral letter or choose and bookCardiologistAppropriate strategy initiated with onward plan/referrals made. Patients requiring DC Cardioversion referred to AF/Flutter ClinicRapid Access Atrial Fibrillation/Flutter ClinicECHO AND ECGBHF ARRHYTHMIA NURSE CLINIC:Review history, symptoms, test and examination resultsPatient educationAgree treatment plan: Rhythm or Rate controlArrange ongoing follow-up, where requiredReferral to cardiology clinic if other cardiac issues identified
5RhythmControlRateControlArrhythmia Nurse Specialist; arrange DC Cardioversion and/or, if indicated:Refer to electrophysiology centre for ablationManage long-term warfarin and rate-control –Primary Care
6 Prepare for DC Cardioversion: DC Cardioversion – DAY SURGERY UNIT Weekly INR (Target ), must have INR >2.0 for four full weeks prior to DC CardioversionDC Cardioversion – DAY SURGERY UNITProcedure and review of medications/onward management plan (Arrhythmia Nurse and Cardiology Specialist Registrar) pre discharge4 Weeks post procedure: Follow-Up with Arrhythmia NurseIs the Patient in Sinus Rhythm and are their symptoms improved/satisfactory?YesNoDepending on clinical indications and patient preference either:Re-attempt DC Cardioversion with additional AA cover (amiodarone)Refer for ablationRate control/Warfarin - (primary Care)Refer to Cardiologist if patient hasongoing symptoms or complications6 Months post procedure: Follow-Up with Arrhythmia NurseIs the Patient in Sinus Rhythm and are their symptoms improved/satisfactory?Cont...
76 Months post procedure: Follow-Up with Arrhythmia Nurse Is the Patient in Sinus Rhythm and are their symptoms improved/satisfactory?YesNoDischarge to primary care and patient advised to seek medical attention if symptoms recurDepending on clinical indications and patient preference either:Re-attempt DC Cardioversion with additional AA cover (amiodarone)Refer for ablationRate control/Warfarin - (primary Care)Refer to Cardiologist if patient hasongoing symptoms or complicationsReview of echo/CHADSVASC SCOREAnti-coagulation post DC Cardioversion:Maintaining a therapeutic INR during the four weeks post DC Cardioversion is essential for All patients regardless of their CHADS–VASc score.Advice with regards to long-term anti-coagulation is based on patients’ CHADS–VASc score rather than the presence of sinus rhythm/absence of atrial fibrillation/flutter on ECG/Holter.