1.2. Atrial Fibrillation Pathway Guidelines for the Community Management of Atrial Fibrillation 1. Algorithm Yes Suspected AF (irregular pulse, palpitations) ECG, FBC, TFT, U&E Confirms AF? Consider alternative diagnosis Consider underlying causes Hypertension CAD Mitral valve stenosis Chest infection/COPD Thyrotoxicosis Heart failure Alcohol Mitral valve stenosis - refer to consultant Treat & review underlying causes No identifiable cause No Yes Rate Control – beta blocker, verapamil or digoxin Is the patient symptomatic despite rate control? Refer to cardiologist Assess thrombotic risk – CHADS 2 score Start anticoagulation therapy if indicated Continue to review regularly to assess symptoms and indications for Refer to cardiologist Unsure No Indications for referral: Paroxysmal AF Additional cardiac problems - need a full cardiological assessment Additional medical problems Poor response to therapy Unable to achieve adequate rate control Symptoms despite adequate rate control Recent onset and reversible precipitant e.g. chest infection, recent cardiac surgery Atrial flutter Heart failure and AF Echo CHADS 2 Score Chronic heart failure +1 Hypertension +1 Age 75 or >75 yrs old +1 Diabetes Mellitus +1 Stroke previously or TIA +2 Maximum score 6 Cardiovascular Joint Formulary Prescribing Guidance (Version 11) (Prepared in collaboration with University Hospitals Birmingham Cardiovascular Consultants and GP Clinical Leads) Prescribing Digoxin Usual dose 250 mcg OD (do not exceed) Reduce dose to 125 mcg OD if < 60 Kg, > 75 yrs or if renal function impaired Use 62.5 mcg od for the very elderly or severe renal dysfunction (eGFR<30) If rapid response needed, load with 500 mcg + 500 mcg 12 hours apart. Beta Blockers – Use Bisoprolol Start at 2.5 mg OD Titrate up weekly to 5, 7.5 or 10 mg to obtain radial rate of 70/min Verapamil Use a SR preparation 120 mg or 240 mg od. Titrate according to radial pulse as above Can be used in combination with 125mcg digoxin but not beta blockers.
18
Embed
1.2 . Atrial Fibrillation Pathway - qcaps.co.uk pathways inc, 24hr ECG, ECHO... · Atrial Fibrillation Pathway Guidelines for the Community Management of Atrial Fibrillation 1. Algorithm
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1.2. Atrial Fibrillation Pathway
Guidelines for the Community Management of Atrial Fibrillation
MEDICAL THERAPY Loop diuretics: For all patients. Commence if peripheral oedema present. Estimate fluid excess in litres. Aim for weight loss of 0.5 kg/day to achieve dry weight. Prescribe loop diuretics without amiloride if on ACE inhibitor. ACE inhibitors and/or ARBs: Either for all patients and combination in NYHA class III and IV. Start at a low dose and uptitrated every 2 weeks to
reach maximum tolerated dose. Measure U + Es at each dose increment. Ensure creatinine does not rise by >20 mol/l and no hypotensive
symptoms. HIGH RISK of first-dose hypotension if: Na <130 mmol/l, systolic BP <100 mmHg, creatinine >200 mol/l, taking > furosemide-equivalent dose of 80 mg/day. If at high risk, refer to HEART FAILURE SERVICE.
*, unlicensed dose, but lower doses not effective
Beta-blockers: Commence once stable on ACE inhibitors and: 1) Free of pulmonary and peripheral oedema; 2) pulse >50 bpm, SBP>90 mmHg. COPD without reversibility is not a contraindication to beta-blockers.
Aldosterone antagonists: For NYHA class III and IV. Start only after referral to HEART FAILURE SERVICE. Close monitoring of U + Es required, ensuring serum K <5.5 mmol/L. Use spironolactone in chronic heart failure. Use eplerenone if gynaecomastia with spironolactone and if an acute MI is followed by symptoms / signs of heart failure and LVSD.
Digoxin: For class III and IV. digoxin 250 g od, or 125 g od if >70 yrs or if renal impairment. Levels not required unless toxicity suspected.
Hydralazine and nitrates: For patients who are intolerant to ACE inhibitors / ARBs.
LICENSED DRUG
INITIAL DOSE
TARGET DOSE
Ramipril * 2.5 mg od 10 mg od
Perindopril 2 mg od 8 mg od
Candersartan 4 mg od 32 mg od
Losartan 25 mg od 150 mg od *
LICENSED DRUG INITIAL DOSE TARGET DOSE
Bisoprolol 1.25 mg od 10 mg od
Carvedilol 3.125 mg bd 50 mg bd
Nebivolol 1.25 10 mg od
LICENSED DRUG INITIAL DOSE TARGET DOSE
Spironolactone 12.5 mg od 50 mg od
Eplerenone 12.5 mg od 50 mg od
Exercise rehabilitation: For all patients. Refer to rehabilitation programme.
If patient improves in NYHA class, do not change drugs, except loop diuretics according to oedema
DEVICE THERAPY Once optimised on medical therapy, ensure all patients have been considered for device therapy:
CRT-P ICD CRT-D
NYVA class III-IV Previous VT or VF with syncope or cardiac arrest VT without syncope or cardiac arrest, plus LVEF<35%
Patients qualifying for CRT-P and ICD
QRS ≥150ms or 120-149 plus dyssynchrony
Previous MI, LVEF<35% and: Non-sustained VT on Holter plus inducible VT on EP testing
LVEF<35% Previous MI, LVEF<30%, QRS ≥120 ms
Optimal medical therapy A familial cardiac condition with a high risk of suddendeath
HEART FAILURE WITH NORMAL EJECTION FRACTION (‘DIASTOLIC’ HEART FAILURE)
Treatment will mainly consist of loop diuretics and antihypertensive treatment. Specialist input required. LONG TERM MONITORING All patients who are optimised on above drugs / device therapy should be monitored at least 6-monthly, to include:
NYHA class, fluid status (oedema), rhythm, U + Es Review of medication and eligibility for devices (see above)
1.4. Calcium Scoring for Stable Chest Pain (UHBfT)
This service is for patients with recent intermittent cardiac chest pain or discomfort suspected to be stable angina,
who require assessment and investigation.
The service provides an alternative pathway for patients who may previously have been referred to the Rapid Access
Chest Pain Clinic but on assessment, have an estimated coronary artery disease (CAD) score of 10-29%, resulting in
them being eligible for direct access to calcium scoring.
Potentially, this helps to streamline the current pathway by reducing the number of patients who are seen in the
Rapid Access Chest Pain Service and then referred onto a consultant cardiology specialist for further assessment.
Appendix 1 provides details of the referral form and pathway into the service
Appendix 1
2. Direct Access Diagnostics
2.1. Direct Access Echo for Atrial Fibrillation
Patients who require an echo to confirm a diagnosis of AF can be referred into the direct access
service at UHBfT using the referral form outlined below. The service can be accessed via a faxed
referral or through choose and book.
Key performance indicators for the service include:
95% of all referred patients seen for a direct access echo within 4 weeks of the referral being made
95% of all tests epo ted to the patie t s GP within 3 working days
95% of all reports coming back to GPs through the electronic links system or fax
CARDIOLOGY REFERRAL
URGENCY OF REFERRAL
Routine Semi Urgent
SPECIALITY REFERRAL
General Electrophysiology Valve Diagnostics Intervention Heart Failure GUCH
INVESTIGATIONS REQUIRED (please tick as appropriate)
Resting ECG 24/48/72 Hour ECG Monitoring 7 Day ECG Monitoring 24 Hour BP Monitoring Echocardiogram for Atrial Fibrillation Has new onset of AF been confirmed by ECG?
Echocardiogram for Heart Failure Please note that this can only be requested after an elavated BNP test or previous MI
1st Language: ........................... Interpreter Required? Y N
GP Name: ............................................................................... Practice: ................................................................ Address/Stamp Tel No: ................................. Fax: .................................... E-mail: .............................................................................. Date of Referral: ...............................................................
Patients who a 24 ECG can be referred into the direct access service at UHBfT using the referral form
outlined in appendix 1. The service can be accessed via a faxed referral or through choose and book.
Key performance indicators for the service include:
95% of all referred patients seen for a direct access echo within 4 weeks of the referral being made
95% of all tests epo ted to the patie t s GP ithi 3 o ki g days
95% of all reports coming back to GPs through the electronic links system or fax
24 Hour Ambulatory ECG Monitoring
Daily Symptoms
(>1 episode per day)
Please refer to inclusion criteria at the
side of the pathway
Refer patient to direct access
service
24 Hour Ambulatory ECG
Had typical symptoms during
Ambulatory Recording?
Yes No
No further investigation
required
GP to reassure patient, monitor
and provide advice on lifestyle,
caffeine and alcohol. Consider
drug therapy
Service Inclusion Criteria
Suspected ectopics of >
2 months duration
Suspected tachycardia
or bradycardia
Service Exclusion Criteria
Known structural or
valvular heart disease
Known coronary artery
disease
Known previous
documented
arrhythmia
Syncope or pre-
syncope
Abnormal 12 lead ECG
Key Performance
Indicators for the
Service
95% of direct access 24 hour ECG referrals seen within 4 weeks of referral being made
95% of direct access 24 hour ECG reports returned to practices via fax or electronic links
95% of direct access 24 hour ECG reports returned to referring GP within 3 working days
Clinically significant arrhythmia
or other abnormal findings?
Yes
Cardiology Consultant
Consultant Opinion
No
Send letter to GP
recommending patient
reassurance and provide
information leaflet
GP
Reassure Patient and
Provide Information Leaflet
2.3. Direct Access BNP Testing for Heart Failure
Diagnosing Heart Failure
Heart Function Centre
Take detailed history and perform a clinical examination
Previous MI No previous MI
GP suspects Heart Failure
O tai lood sa ple i ed top tu e & e uest BNP test i Othe o biochemistry request form
Send specimen to secondary care lab on the same day
(DO NOT STORE OVERNIGHT)
High levels Raised levels
Specialist assessment &
Doppler echocardiography
Within 2
weeks
Abnormality consistent with
Heart Failure
No clear abnormality Normal Levels
Consider measuring natriuretic
peptides if levels not known
Assess severity, aetiology, precipitating factors, type of cardiac dysfunction,
correctable causes Raised levels
Investigate other
diagnoses Other cardiac
abnormality
Heart Failure due to left
ventricular systolic
dysfunction
Heart Failure with
preserved ejection
fraction Heart Failure unlikely,
other diagnosis
Within 2
weeks
Within 6 weeks
Serum Natriuretic Peptides
High levels – BNP >400pg/ml (116pmol/litre) or NTproBNP >2000pg/ml (236 pmol/litre)