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

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

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 > 75 2 Diabetes mellitus 1 Stroke / TIA 2 Vascular disease 1 Age 65-74 1 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    

(Form attached. Also available on the intranet Paroxysmal NEED FURTHER ADVICE? ARRHYTHMIA NURSE: 01305 254920   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

  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

Prepare for DC Cardioversion: DC Cardioversion – DAY SURGERY UNIT Weekly INR (Target 2.5-3.0), 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...

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.

Over to You – Any Questions?