Community Management of Atrial Fibrillation
History and examination:
- Establish extent of symptoms, including duration and frequency.
- Determine any acute triggering factors eg. intercurrent illness, thyroid disease, ETOH
- Review relevant conditions eg. hypertension, cardiac disease, lung disease
- Discuss relevant family history eg. of sudden death suggesting underlying structural abnormality
- Assess thromboembolic and bleeding risks (see later).
- Review medications including proarrhythmic agents and previous intolerances.
- Record examination findings including BP, heart rate, murmurs and any evidence of failure.
ECG:
- Confirmation of rhythm and rate ( remember in CHB or if permanently paced AF will appear regular)
- Evidence of structural heart disease
Bloods:
- FBC, U&Es, LFTS, TFTs, Ca, Cholesterol, coagulation screen.
CXR:
- To exclude underlying lung pathology or heart failure
Echocardiogram:
All patients with Atrial Fibrillation should have an echocardiogram to exclude structural abnormalities unless:
- there has been a previous study and there is no suspicion of change (eg. no new murmurs, no change in clinical status out of keeping with new rhythm and rate )
- the presence of structural heart disease will not alter management (eg. elderly patients +/- those with multiple comorbidities who are asymptomatic or who may be best managed in the community and would not wish or are not suitable for invasive management /surgery).
If an Echo is not mentioned in the referral letter, it will be assumed that one has not been requested and therefore Cardiology may request one.
Consider 24 hour tape:
- Patients with on-going symptoms despite adequate heart rate at rest/short walk
- Symptoms suggestive of additional bradyarrythmia
- Patient activity diary is vital to correlate rates with exertion undertaken in addition to symptoms.Remember asymptomatic pauses < 2.8secs daytime and < 4 secs nightime are generally acceptable.
Manage modifiable risks to reduce frequency of episodes:
- Alcohol, caffeine,stress, thyroid/lung disease,
- Electrolyte imbalance- particularly low potassium ( at greater risk on thiazide diuretics )
- Tight blood pressure control ( ACE inhibitors may be of particular benefit )
- Heart failure treatment optimised
Anticoagulation
Please calculate the CHA2DSVASc score and include this in the referral letter.
Rate Control
- Beta blockers as first line agent. Standard preparation eg atenolol or cardioselective eg. bisoprolol in those who have experienced side effects
- If there are definite contraindications to a B-Blocker try rate slowing calcium channel antagonist in absence of heart failure.
- Remember cardioselective beta blockers may be tolerated in COPD )
- Digoxin can be used as an adjunct to these agents for improved rate control. It is not as effective at controlling rate in active patients and is therefore recommended for use as a lone agent only in the sedentary patient deemed at high risk of side effects or those with contraindications or intolerance beta blockers/calcium channel antagonisits.
Rhythm Control
For most patients there is no clear prognostic benefit from rhythm control as opposed to rate control strategy (presuming adequate rate control)
Patients with heart failure may benefit from maintenance of sinus rhythm.
The patient should be included in the discussion regarding management strategy and be aware that if at high risk of stroke lifelong oral anticoagulation may be recommended even if sinus rhythm is restored.
If patients revert to sinus rhythm during treatment patients are manage as for paroxysmal atrial fibrillation.
- Amiodarone in the absence of contraindications, can be considered as a next step only in selected patients eg. elderly (less likely to develop long term side effects) or those with comorbidities who are best served by on-going management in the community. Consider potential side effects . Monitor LFTS and TFTs.
- Other antiarrhythmics are only recommended for use in the community if advised by Cardiologist .
References / further reading:
NICE Guidelines https://www.nice.org.uk/guidance/cg180
Date reviewed 05/07/2021
Next review due 05/07/2022
Sifter name Elizabeth Fell / Bridgitte Wesson
Contributors Dr Louise Melley – Assistant Specialist Cardiology RCHT
Version 1.3