Clinical pathway for people with atrial fibrillation or at risk of atrial fibrillation Dr Ruth Chambers OBE LTC Priority Lead, West Midlands Academic Health Science Network and Chair, Stoke-on-Trent CCG

Background In 2015 Cheshire & Merseyside SCN published a pathway initiative for patients with or at risk of atrial fibrillation The pathway was developed by disease experts and commissioners from across the Cheshire & Merseyside area, supported by the C&M Cardiac Network, funded by Boehringer Ingelheim and led by Stephen Callaghan of EQE Health The target audience included: Providers of AF-related services Primary Care Patients Consultants in public health Public health commissioners Clinical Commissioning Groups NHS England Link to pathway document: http://www.cmscnsenate.nhs.uk/files/1414/4543/7970/AF_Pathway_Master_FINAL_OCTOBER_2015.pdf?PDFPATHWAY=PDF 25/02/2016

Aims of the pathway The short and long-term aims of introducing and implementing a pathway for AF across different care settings are based on five fundamental principles: 1 Prevention of AF 2 Early detection of AF 3 Treatment of AF in acute and long-term settings 4 Reduction of complications (e.g. stroke, thrombo-embolic disease and heart failure) 5 Support at the end of life 25/02/2016

The Pathway 25/02/2016

Prevention of AF Primary prevention: Maintaining a heart-healthy lifestyle Treatment of other underlying conditions that can contribute to the onset of AF: Sleep apnoea Thyroid disease Diabetes Obesity Chronic lung disease Other heart conditions Secondary prevention: Anticoagulation (in accordance with CHA2 DS2 -VASc) Regular physical activity Heart-healthy diet, low in saturated fats, trans fats, and cholesterol Management of high blood pressure Avoiding excessive amounts of alcohol and caffeine Smoking cessation Cholesterol control and maintaining a healthy weight 25/02/2016

First stage - Targeted & opportunistic screening Purpose of this stage: To identify individuals with atrial fibrillation early in order to initiate treatment and reduce risk of adverse events (stroke or transient ischaemic attack, thromboembolism or heart failure). 25/02/2016

Second stage - Identification & assessment of AF Purpose of this stage: Accurate detection and confirmation of atrial fibrillation and an assessment as to its cause. 25/02/2016

Third stage – Initial management Purpose of this stage: To provide confidence for primary care to manage stable atrial fibrillation (AF) and clarify the place of specialist services. 25/02/2016

Fourth stage - Long-term management Purpose of this stage: Provide a robust and continuous monitoring system to ensure adequate treatment is given for prevention of strokes in patients who are previously or currently diagnosed with atrial fibrillation. Continually assess patient symptoms and how they affect their quality of life and allow access to specialist services if required. 25/02/2016

Anticoagulation for AF patients Decision to anticoagulate should be based on their CHA2 DS2 -VASc and HAS-BLED scores NICE recommends anticoagulation with either a novel oral anticoagulant agent (NOAC) such as direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban), direct thrombin inhibitors (Dabigatran) or Vitamin K antagonist such as warfarin. 25/02/2016

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Reference Cheshire & Merseyside Strategic Clinical Network (2015). Clinical pathway for people with atrial fibrillation or at risk of atrial fibrillation. http://www.cmscnsenate.nhs.uk/files/1414/4543/7970/AF_Pathway_Master_FINAL_OCTOBER_2015.pdf?PDFPATHWAY=PDF 25/02/2016