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AF (Confirmed) Management in Primary Care
In scope This care map relates to the initial management of patients with persistent/ permanent or paroxysmal AF and those with confirmed persistent/ permanent AF who have already been deemed appropriate for management in primary care.
Out of scope This pathway does not cover diagnosing AF (this is dealt with in the pathway AF Suspected) and this pathway does not cover anticoagulation for patients with AF (this is dealt with in the pathway Anticoagulation which is under development)
Confirmed or likely
persistent or paroxysmal
AF Click for
more info
See pathway AF – Suspected RED FLAGS Click for more info
If RED FLAGS, refer to on-call medical team for urgent assessment
See pathway Management of Suspected Stroke
Consider if patient needs anticoagulant
Cardiological management of persistent/ permanent AF
- All patients should be assessed for underlying causes and have symptomatic management in primary care even if they are subsequently referred to cardiology
- Some patients can be safely managed in primary care
Initial investigations
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Consider and address underlying causes of AF
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Consider if rate or rhythm control needed
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Consider starting rate control medication
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Consider ECHO
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Consider referral to cardiologist
Refer to cardiologist
Review/reconsider rate control medication while waiting to see a cardiologist
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Seen by cardiologist
Decision to manage in primary care May be appropriate in asymptomatic, relatively inactive, frailer patients, without known LV impairment/heart failure or according to informed patient preference. Refer other patients for cardiological opinion
Consider rate control treatment options
- resting heart rate is 90 beats per minute or more
- heart rate is fast on exertion, resulting in limited exercise tolerance
Review/reconsider rate control medication
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Continue to reduce stroke risk and monitor patient
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Monitor progress
- follow-up one week
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Uncontrolled or RED FLAG! symptomatic AF
If RED FLAGS, refer to on-call medical team for urgent assessment
Review treatment options Click for more info
Consider referral to cardiologist
AF rate controlled without symptoms
Continue to reduce stroke risk and monitor patient at least annually
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Cardiological management of paroxysmal AF NICE advises that all patient with paroxysmal AF should be referred to a cardiology specialist, but patients preferences should be taken into account
Refer paroxysmal AF to cardiology
Consider starting medication for rate control while waiting to see a cardiologist
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Investigations
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Seen by cardiologist
If symptoms are not controlled with, or patient does not tolerate, a beta-blocker plus digoxin or a calcium-channel blocker plus digoxin
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pathway Confirmed or likely persistent or paroxysmal AF
Definitions:
- Paroxysmal AF, (PAF), lasts less than 7 days, with the majority of episodes terminating within 48 hours.
- persistent AF is present when an AF episode either lasts longer than 7 days or requires termination by cardioversion
- long-standing persistent AF has lasted for 1 year or longer when it is decided to adopt a rhythm control strategy
- permanent AF is said to exist when the presence of the arrhythmia is accepted by the patient (and physician) - rhythm control interventions are, by definition, not pursued in patients with permanent AF
pathway Initial investigations
NB: If referral is considered appropriate do not wait for results of investigations before referring
Consider the following routine investigations:
- full blood count (FBC) - to exclude anaemia. Haemoglobin for safety reasons and to get baseline value for future monitoring
Platelets to get a baseline value when monitoring bleeding risk.
- blood urea and electrolytes, calcium, magnesium, to exclude electrolyte disturbances, which may precipitate AF
- creatinine and eGFR
- thyroid function tests
- chest radiography - to investigate a suspected lung abnormality, e.g. lung cancer, or detect heart failure
NB: additional tests are needed prior to anticoagulation:
pathway Consider and address underlying causes of AF
- often caused by co-existing medical conditions - both cardiac and non-cardiac
- common cardiac causes include:
- ischaemic heart disease - specifically mitral valve disease
- hypertension
- sick sinus syndrome
- pre-excitation syndromes, e.g. Wolff-Parkinson-White
- less common cardiac causes include:
- cardiomyopathy or hear muscle disease
- pericardial disease, including effusion and constrictive pericarditis
- atrial septal defect
- atrial myxoma
- non-cardiac causes include:
- acute infections, especially pneumonia
- electrolyte depletion
- lung carcinoma
- other intrathoracic pathology, e.g. pleural effusion
- pulmonary embolism
- thyrotoxicosis
Risk factors include:
- increasing age:
- the prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age 50-59 years to almost 9% at age 80 - 89 years
- AF is very uncommon in infants and children, unless concomitant structural or congenital heart disease is present
- diabetes mellitus (DM)
- hypertension
- valve disease
- surgery, especially cardiothoracic operations such as thoracotomy and coronary artery bypass graft
- lifestyle factors, such as:
- excessive alcohol consumption
- excessive caffeine consumption
- emotional or physical stress
pathway Consider starting rate control medication
Rate control Offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem (off-label) or verapamil) as initial monotherapy to people with atrial fibrillation who need drug treatment as part of a rate control strategy.
Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences when considering drug treatment.
Consider digoxin monotherapy for people with non-paroxysmal atrial fibrillation only if they are sedentary.
If maximally tolerated monotherapy with a rate-limiting calcium-channel blocker (diltiazem (off-label) or verapamil) or a beta-blocker does not fully control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider adding in digoxin.
If maximally tolerated monotherapy with digoxin does not fully control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider adding in a rate-limiting calcium-channel blocker (diltiazem (off-label) or verapamil) or a beta-blocker.
https://cks.nice.org.uk/atrial-fibrillation
Do not offer amiodarone for long-term rate control.
pathway
Consider ECHO
Perform transthoracic echocardiography (TTE) in people with atrial fibrillation:
- for whom a baseline echocardiogram is important for long-term management
- for whom a rhythm-control strategy that includes cardioversion (electrical or pharmacological) is being considered
- in whom there is a high risk or a suspicion of underlying structural/functional heart disease (such as heart failure or heart murmur) that influences their subsequent management (for example, choice of antiarrhythmic drug or anticoagulant)
- in whom refinement of clinical risk stratification for antithrombotic therapy is needed
pathway Continue to reduce stroke risk and monitor patient at least annually
At least annual review of CHA 2 DS 2 VASc and HAS-BLED scores are needed with review of symptoms, blood pressure and appropriate treatment and life-style advice to prevent stroke and referral to consultant cardiologist where appropriate.
Do not offer antithrombotic therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA 2 DS 2 VASc score of 0 for men or 1 for women).
Reviewing established atrial fibrillation (AF):
- check for ongoing symptoms, both at rest and upon exercise
- assess heart rate
- check for complications of AF and assess blood pressure - identify and manage existing heart failure or hypertension
- review the patient's medication:
- if patient is currently taking anticoagulants, reassess risk of bleeding, including risk of falls
- check compliance and identify and manage drug interactions and complications, such as dyspepsia with aspirin
- give advice on known drug interactions and which drugs should be avoided with anticoagulants
pathway Monitor progress - follow-up one week
Follow-up within 1 week:
- Check whether the patient is tolerating the medication - if the patient is unable to tolerate the current medication, prescribe an alternative
- Review symptoms, heart rate, and blood pressure
Check for ongoing symptoms, both at rest and upon exercise
- assess heart rate and assess blood pressure
- check for complications of AF - identify and manage existing heart failure or hypertension
- review the patient's medication:
- if patient is currently taking an anticoagulant, reassess risk of bleeding, including risk of falls
- check compliance and identify and manage drug interactions and complications
- give advice on known drug interactions and which drugs should be avoided with aspirin or warfarin
