New Atrial Fibrillation/Flutter Pathway and GRASP Tool

Kay Elliott Arrhythmia Nurse Specialist

Dorset County Hospital NHS Foundation Trust

New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell?

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

NEW ONSET ATRIAL NEW ONSET ATRIAL FIBRILLATION/FLUTTERFIBRILLATION/FLUTTER

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Care

Initiate appropriate stroke/TIA prophylaxis according to CHADS–VASc score (BOX A)

and Initiate appropriate rate control (BOX B)

BOX A: CHADS–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

CHADS–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.

Paroxysmal PersistentNEED FURTHER ADVICE?

ARRHYTHMIA NURSE:

01305 254920

 

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

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

Refer to cardiology team: referral letter or choose and book

CardiologistAppropriate strategy initiated with onward plan/referrals made. Patients requiring DC Cardioversion referred to AF/Flutter Clinic

 

  RhythmControl

RateControl

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:Weekly INR (Target 2.5-3.0), must have INR >2.0 for four full weeks prior to DC Cardioversion

DC Cardioversion – DAY SURGERY UNITProcedure and review of medications/onward management plan (Arrhythmia Nurse and Cardiology Specialist Registrar) pre discharge

4 Weeks post procedure: Follow-Up with Arrhythmia NurseIs the Patient in Sinus Rhythm and are their symptoms improved/satisfactory?

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

Yes

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 NurseIs 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

Anti-coagulation post DC Cardioversion:Maintaining a therapeutic INR during the four weeks post DC Cardioversion is essential for All patients regardless of their CHADS–VASc score. Advice with regards to long-term anti-coagulation is based on patients’ CHADS–VASc score rather than the presence of sinus rhythm/absence of atrial fibrillation/flutter on ECG/Holter.

Over to You – Any Questions?Over to You – Any Questions?