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/FLUTTER
New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell?
Yes 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
Acute breathlessness/chest pain
High risk of deterioration; fast ventricular rate +/- age, co-morbidities
Bradycardia/syncopal episodes

3. BOX A: CHADS–VASc Scoring
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 Factor Point
Heart Failure/LV Dysfunction 1
Hypertension 1
Aged >
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.
NEED FOR CLOSER MONITORING RATE CONTROL, INITIATION OF WARFARIN CONTROL
IF CHADS2 = 2 OR ABOVE NO NEED TO DO CHADSVASC
C – heart failure
H – hypertension
A - > 75 years
D – Diabetes
S – Stroke/TIA – 2 points

4. (Form attached. Also available on the intranet
Paroxysmal
NEED FURTHER ADVICE?
ARRHYTHMIA NURSE:
Persistent
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
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
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

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: DC Cardioversion – DAY SURGERY UNIT
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?
Yes 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
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?
Yes No
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
Review of echo/CHADSVASC SCORE
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?