Atrial fibrillation: diagnosis and management

• Manual pulse check if: SOB/palpitations/syncope/dizzy/stroke/TIA/chest pain/opportunistic
• 12 lead ECG if irregular pulse detected
• Cardiac monitor if ECG normal but suspicion of paroxysmal AF (Consider repeating if asymptomatic during the period of recording)

Check for secondary causes if suspected

• Alcohol intake (history)
• Thyroid dysfunction (TSH)
• Anaemia (FBC)
• Chest infection (examination),
• Structural or functional heart disease. E.G. heart failure, valve disease (examination/ECHO)

Acute onset

• If onset <48 hours and considered reversible cause refer immediately for consideration of electrical or chemical cardioversion (For chemical cardioversion use Flecainide (if no structural or ischaemic heart disease) or Amiodarone)

• If onset >48 hours treat as below

Rate v rhythm control

• Use a rate control strategy first line. Consider a rhythm control strategy if:
  • Reversible cause/ new onset
  • Heart failure felt to be caused by AF
  • AF felt suitable for ablation
  • Rate control fails to control symptoms
• If a rhythm control strategy is considered commence anticoagulation as below (will need 3 weeks of
  adequate anticoagulation prior to cardioversion)

Rate Control (aim to control symptoms rather than aiming for a specific heart rate)

• First Line: use either a beta blocker (e.g. Bisoprolol 1.25-10mg/day) or a rate limiting calcium
  channel blocker (e.g. Diltiazem 120-360mg/day).
  Only consider Digoxin 62.5-250mcg as monotherapy in sedentary patients with permanent AF (not
  suitable for Paroxysmal AF)
• If rate/symptoms are not controlled on one agent use any two of beta blocker, Diltiazem, or Digoxin.
• Do not use Amiodarone for rate control (review its use if patient develops persistent/permanent AF)

Rhythm Control

• Consider Amiodarone commencing 4 weeks before cardioversion and continuing for up to 12 months after cardioversion to help maintain sinus rhythm (d/w secondary care)
• For maintenance consider a standard beta blocker (e.g. Bisoprolol 1.25-10mg/day)
• Dronaderone can be considered under specialist advice as an alternative for maintenance of sinus
  rhythm
• Consider referral for Ablation or other procedures if patient remains symptomatic

Assessment

• Calculate CHA2DS2-VASC score (see below)
• Calculate ORBIT BLEEDING RISK score (see below)
  • Aim to correct any modifiable factors on ORBIT score before deciding re anticoagulation
    (hypertension, alcohol consumption, concurrent medication (e.g., NSAIDS), Labile INR)
• When deciding with the patient whether or not to use anticoagulation remember:
  • For most people the benefits of anticoagulation outweigh the risks
  • If there is a significant bleeding risk this should be monitored on patients who choose anticoagulation
  • Anticoagulation should not be withheld solely because the person is at risk of having a fall.

Treatment: decision support

• Do not offer treatment to patients with a CHA2DS2-VASC of 0 (for men) or 1(for women)
  All patients with CHA2DS2-VASC of 2 or more should be offered anticoagulation (after taking bleeding
  risk into account) (Consider in men with CHA2DS2-VASC of 1)
• Do not offer aspirin monotherapy for stroke prevention for patients with AF
• For patients who are not offered anticoagulation arrange regular review (annual?) to look for change in
  clinical status warranting a reassessment of risk (development of diabetes etc.)

Treatment: Choice of Drug

• 1st line Apixaban (usual dose 5mg twice a day, reduce dose to 2.5mg twice a day in patients with any
  two of the following characteristics: age 80 years and over, body-weight less than 61kg, or serum
  creatinine 133 micromol/litre and over)
• 2nd line Warfarin (or alternative oral Coumadin drug): Target INR 2.5 (Range 2-3)
  For patients already on Warfarin consider switching to Apixaban if:
  • There is poor INR control
    • 2 INR values > 5 or 1 INR > 8 in the last 6 months
    • 2 INR values < 1.5 in the last 6 months
    • Time in Therapeutic Range <65%