Management of Atrial Fibrillation in Primary Care Dr Matthew Fay Westcliffe Medical Practice Shipley Westcliffe Cardiology Service
Management of Atrial Fibrillation in Primary Care
Feb 11, 2016
Westcliffe Medical Practice Shipley Westcliffe Cardiology Service. Management of Atrial Fibrillation in Primary Care. Dr Matthew Fay. Bradford Airedale tPCT. Who should be doing what? The PCT Primary Care Intermediate Care. Westcliffe Medical Practice Shipley - PowerPoint PPT Presentation
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Management of Atrial Fibrillation in Primary Care
Dr Matthew Fay
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
Bradford Airedale tPCT•Who should be doing what?
–The PCT– Primary Care– Intermediate Care
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
What should the PCT do?• Increasing awareness of AF in the population• Encouraging people to attend for health checks to ensure
that this condition has not developed asymptomatically.• Screening of the over 65 population should be
encouraged with a local incentive scheme.
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
% practice list over 65 plotted against %AF prevalence
y = 0.0465x + 0.0081R2 = 0.2468
y = 0.067x - 0.0011R2 = 0.6379
y = 0.0399x + 0.0053R2 = 0.2133
y = 0.0945x - 0.0012R2 = 0.3995
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
0% 5% 10% 15% 20% 25% 30% 35%
% practice list >65
% A
F pr
eval
ence
Airedale City S&W YPCA
Prevalence AF by practice
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
% Over 65yrs by practice
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
Direct Comparison
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
What Should the GP do?• Assess patients with symptoms suggestive of AF• Incidental screening while reviewing for other problems• Initiate preliminary investigations such as:
– 12 Lead ECG– FBC– Electrolytes– Liver function and Gamma GT– Thyroid Function
•Appropriately risk stratify
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
What Should the GP do?• Initiate appropriate antithrombotic therapy• Initiate patient education• Initiate rate limiting medication• Assess patient progress• Refer on if rate over rhythm therapy not effective• Refer on if alternative pathology suspected
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
What should Enhanced General Practice do?•Appropriately perform and interpret an ECG
•Initiate anticoagulation as appropriate
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
What should Intermediate Cardiology
Services do?• To assist other practices in the interpretation of ECGs• Receive referrals directly from other practices• To assist in the diagnosis and management of patients
presenting with possible Paroxysmal Atrial Fibrillation. • To assist in the decision of Rate over Rhythm management
and if the latter to ensure rapid referral to locality anticoagulation services and referral to DC Cardioversion to obtain optimum treatment intervals for effective intervention
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
What should Intermediate Cardiology
Services do?• Arrange locality echocardiography in individuals where questions regarding the suitability of anticoagulation or possibility of successful Cardioversion are in question.
• Receive patient back from secondary care cardioversion services to monitor progress and reassess medication strategies dependant on the success of cardioversion.
Westcliffe Medical PracticeShipley
Westcliffe Cardiology Service
Patient Presents
Initial Assessment
Acutely compromised
Emergency Admission
Patient stable
12 Lead ECG confirms Atrial
Fibrillation
On set of symptoms <48hous
Referral to Rapid access Cardioversion service
On set of symptoms >48
hours
Rhythm management appropriate
Referral to intermediate Cardiology service
Rate management appropriate
Assess Antithrombotic therapy needs
Antiplatelet therapy
appropriate
Anticoagulant therapy
appropriate
Refer to local anticoagulation service
Disagree Rhythm management appropriate
Agree Rhythm management appropriate
High risk of Cardioversion failure?
No Yes
Clearly other issues requiring cardiologist
intervention
Cardiology Review
Patient stable
12 Lead ECG confirms Atrial
Fibrillation
On set of symptoms <48hous
Referral to Rapid access Cardioversion service
On set of symptoms >48
hours
Rhythm management appropriate
Referral to intermediate Cardiology service
Rate management appropriate
Assess Antithrombotic therapy needs
Antiplatelet therapy
appropriate
Anticoagulant therapy
appropriate
Refer to local anticoagulation service
Initiate betablocker or rate limiting calcium channel blocker as appropriate
Disagree Rhythm management appropriate
Agree Rhythm management appropriate
High risk of Cardioversion failure?
Anticoagulate and list for DC external cardioversion
Anticoagulate. Commence sotalol or amiodarone and list
for DC external cardioversion
No Yes
Return to intermediate cardiology service for follow up post cardioversion
Clearly other issues requiring cardiologist
intervention
Cardiology Review
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