Atrial Fibrillation and Flutter

Principles of Management

If a patient presents with significant symptoms or a complication of AF, admit patient or discuss with on call cardiologist  (see red flags section below)

For patients not requiring admission then initially identity and manage any underlying cause or trigger. Uncomplicated Atrial Fibrillation can often be managed in primary care. The following advice is based on NICE guidelines and advice from Ed Duncan - consultant cardiologist at UHBW. 

Diagnosis

• If an irregular pulse is detected then arrange an ECG or consider using a portable ecg recorder (KardiaMobile now approved by NICE)

• If paroxysmal AF is suspected and an initial ecg is normal, then organise an ambulatory ecg. Please see the Cardiac Rhythm Analysis section for details on how to refer. If symptoms are  infrequent and unlikely to be captured by standard ambulatory monitoring then the patient should be advised to attend their GP surgery or A+E during an episode for an ECG.

• Arrange blood tests to check for an underlying cause - FBC, TFT, UE, HbA1c, LFT, Clotting Screen.

• Consider a CXR if lung pathology suspected.

• Consider an echocardiogram if there are concerns about underlying structural heart disease (such as a heart murmur) or functional heart disease (such as heart failure) that will influence their subsequent management (for example choice of antiarrhythmic drug).

Management

1. Lifestyle modification - controlling lifestyle factors can significantly reduce AF burden. In particular reduction in alcohol intake, blood pressure control, weight loss and moderate exercise.

2. Anticoagulation - assess stroke risk using CHA2DS2VASc and bleeding risk using ORBIT or HAS-BLED  and start anticoagulation treatment if appropriate (see anti-coagulation section below for further details). Use installed EMIS AF assessment template to assess stroke risk*.

3. Rate control - use a betablocker (not sotalol) or rate limiting calcium channel blocker (e.g Diltiazem or verapamil) to reduce the heart rate if necessary. Digoxin is a possible alternative in people with non‑paroxysmal AF if they do little or no exercise, or if other rate-limiting drug options are ruled out because of comorbidities or the person's preferences. Do not offer amiodarone for long-term rate control. (1)

4. Rhythm control - consider referral for cardiology if appropriate. See Referral to Cardiology section below for further advice.

Advice from Local Cardiologists

You may also consider a referral to Cardiology Advice and Guidance service for more individual advice if required.

NICE guidelines

See Clinical Knowledge Summaries (updated October 2021) for further advice on diagnosis and management.

* Prior to July 2019 there were some errors in the EMIS CHA2DS2-VASc calculator that may have overestimated risk in some patients. Please see the relevant section in the bulletin below:

Clinical Safety Issue - CHA2DS2-VASc calculator

Red Flags

Admit or discuss with on call cardiologist if the patient has any of the following:

• Signs of haemodynamic instability such as a rapid pulse (greater than 150 beats per minute) and/or low blood pressure (systolic blood pressure less than 90 mmHg), loss of consciousness, severe dizziness or syncope, ongoing chest pain, or increasing breathlessness.

• A complication such as stroke, transient ischaemic attack, acute heart failure, pulmonary embolism or thyrotoxicosis.

Anticoagulation

Clinical Knowledge Summaries has guidelines on when to prescribe an anticoagulant and how to assess bleeding risk. The guidelines link to the following tools that should be used in assessment:

• CHA₂DS₂VASc  - this risk tool also available in EMIS templates.
• ORBIT - this is now the NICE recommended tool for assessing bleeding risk although HAS-BLED is still also widely used.

Anticoagulant treatment is generally indicated by CHA₂DS₂VASc scores of two or more, and treatment should also be considered for males with a score of one or more (this includes patients with either paroxysmal or persistent AF)

Choice of Anticoagulant

Aspirin monotherapy should not be offered as stroke prophylaxis in AF.

DOAC's are increasingly the anticoagulant of choice in patients with non-valvular AF (i.e. AF not related to prosthetic heart valves or severe mitral stenosis - warfarin should be used in these patients). 

Warfarin is still indicated if DOAC's are not indicated or not tolerated.

Please see the BNSSG formulary pages for full Anticoagulation guidance.

Atrial Flutter

Atrial Flutter should be managed in the same was as atrial fibrillation. Ed Duncan (Consultant cardiologist at BHI) advises:

• Anticoagulate as per atrial fibrillation
• Rate control as per atrial fibrillation (although this can prove difficult)
• Avoid flecainide
• Have a low threshold for referral to Cardiology as atrial flutter responds very well to ablation.
• Consider conservative management if  the patient has co-morbidities, is rate controlled and has a low symptom burden.

If you require more specific advice about referral for rhythm control, you can access the Cardiology Advice and Guidance Service via e-RS.

Referral

Refer to a cardiologist for consideration of rhythm-control treatment (cardioversion, drugs or ablation), people :

• With clear onset of new symptoms of AF (within last 48 hours).

• Whose AF has a reversible cause (for example a chest infection).

• Who have heart failure thought to be primarily caused, or worsened, by AF.

• With atrial flutter who are considered suitable for an ablation strategy to restore sinus rhythm.

• For whom a rhythm-control strategy would be more suitable based on clinical judgement and ongoing symptoms.

If the onset of arrhythmia is more than 48 hours or uncertain then start rate-control treatment. If referral for consideration for rhythm-control treatment (cardioversion) is thought to be necessary using clinical judgement, cardioversion should be delayed until the person has been maintained on therapeutic anticoagulation for a minimum of 3 weeks

If you require more specific advice about referral for rhythm control, you can access the Cardiology Advice and Guidance Service via e-Referral.

Resources

(1) Atrial Fibrilliation - CKS guidelines (October 2021)

(2) Cardiovascular System Guidelines - BNSSG formulary - includes DOAC decision aid and other anticoagulation guidelines.

(3) DVLA advice regarding medical fitness to drive can be obtained at www.gov.uk/government/publications/at-a-glance.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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