Ann Int Med Vol150 Is6 Pg396 F1


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  • You can add your own organisation’s logo alongside the NICE logo DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
  • NOTES FOR PRESENTERS NICE clinical guidelines aim to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills. Standards for better health, issued in July 2004 by the Department of Heath, identifies core and developmental standards for NHS organisations. Core standard C5 states that healthcare organisations should take into account nationally agreed guidance when planning and delivering treatment and care. Implementation of clinical guidelines forms part of developmental standard D2 which states that patients should receive effective treatment and care that conforms to nationally agreed best practice, particularly as defined in NICE guidance.
  • NOTES FOR PRESENTERS For more details, refer to the full guideline – page 11, section 1.1
  • NOTES FOR PRESENTERS There are many risk factors for developing AF. In the Framingham study, the development of AF was associated with increasing age, diabetes, hypertension and valve disease. It is also commonly associated with, and complicated by, congestive heart failure and strokes. Dietary and lifestyle factors have also been associated with AF, such as excessive alcohol and caffeine, as well as emotional and physical stress. Cardiac causes of AF Common cardiac causes: Ischaemic heart disease Rheumatic heart disease Hypertension Sick sinus syndrome Pre-excitation syndromes (e.g. Wolff-Parkinson-White syndrome) Less common cardiac causes: Cardiomyopathy or heart muscle disease Pericardial disease (including effusion and constrictive pericarditis) Atrial septal defect Atrial myxoma Non-cardiac causes of AF Acute infections, especially pneumonia Electrolyte depletion Lung carcinoma Other intrathoracic pathology (e.g. pleural effusion) Pulmonary embolism Thyrotoxicosis Refer to the full guideline – page 89, section 10 Post-op AF is associated with a greater risk of mortality and morbidity, and evidence is emerging that post-op AF predisposes people to a significantly increased risk of stroke and thromboembolism. The next slide highlights the classification of AF, which is based on the temporal pattern of the arrhythmia.
  • NOTES FOR PRESENTERS For more details, refer to the full guideline, pages 11 and 12, section 1.2 AF is considered recurrent when a patient develops two or more episodes. These episodes may be paroxysmal if they terminate spontaneously, defined by consensus as terminating within seven days, or persistent if the arrhythmia requires electrical or pharmacological cardioversion for termination. Successful termination of AF does not alter the classification of persistent AF in these patients. Longstanding AF (defined as over 1 year) not successfully terminated by cardioversion, or when cardioversion is not pursued, is classified as permanent. Without treatment, AF can result in some degree of disruption to the circulation of blood around the body. In some cases of AF, the degree of haemodynamic instability can represent a critical condition that requires immediate intervention. The next slide sets out why we need this guideline.
  • NOTES FOR PRESENTERS For more details, refer to full guideline - pages 13-15, section 1.3 The adverse effects of AF are the result of haemodynamic changes related to the rapid and/or irregular heart rhythm and thromboembolic complications related to a prothrombotic state associated with the arrhythmia. The prothrombotic state predisposes to stroke and thromboembolism in AF, with an approximately five-fold risk that of people without AF. An uncontrolled AF may precipitate critical cardiac ischaemia. AF can also result in reduced exercise tolerance as well as impairment in cognitive function, directly affecting the patients quality of life. There is wide variation in provision. The next slide provides information about the prevalence of AF.
  • NOTES FOR PRESENTERS Refer to the full guideline – pages 11 and 12, 1.1 and 1.3 In the West Birmingham AF project, the prevalence of AF was 2.4% in two general practices. The Newcastle survey screened 4843 people aged 65 years or over in general practices, and found a prevalence of AF of 4.7%. AF is very uncommon in children and infants, unless concomitant structural or congenital heart disease is present. This guideline does not cover children and young people under the age of 18 years. AF is often caused by co-existing medical conditions – these can be cardiac and non-cardiac (see page 14 of the full guideline). AF is also common after surgery, especially cardiothoracic operations, and the presence of AF may result in prolongation of hospital stay. It may also increase the risk of heart failure, stroke or thromboembolism, resulting in greater hospital costs.
  • NOTES FOR PRESENTERS Refer to the full guideline – page 13, table 1.01. Renfrew-Paisley UK study, cohort of men and women aged 45-64 years (n = 15,406) there were 100 documented cases of AF. Prevalence of AF increased with age and more cases were detected in men.
  • NOTES FOR PRESENTERS These points are covered in more detail in the remaining slides. There are two main treatment strategies: rate-control and rhythm-control. Refer to the full guideline – pages 26 and 27, sections 3.2 and 3.3; and page 64, section 6.1 Page 26 shows the full AF care pathway algorithm Page 27 shows the treatment strategy decision tree algorithm
  • NOTES FOR PRESENTERS Here is a care pathway is for a typical patient.
  • NOTES FOR PRESENTERS Rationale: there are too many missed diagnoses of AF that result in preventable stroke …and pulse palpation is accurate and easy! People presenting to primary or secondary care and noted to have an irregular pulse should have an ECG performed, and any new diagnosis of AF should be recorded.
  • NOTES FOR PRESENTERS Refer to the NICE guideline – page 8. AF may be symptomatic or asymptomatic – episodes of both can occur in the same patient. Many patients can be picked up in general practice – promote the new QOF indicators and targets. It is considered good practice to check the blood pressure and pulse (manually) in all patients who present with breathlessness, dyspnoea, palpitations, syncope/dizziness or chest discomfort. Many patients presenting with stroke are also found to be have AF. The next slide lists more suggested actions.
  • NOTES FOR PRESENTERS An ECG should be performed to confirm the diagnosis of AF, whether symptomatic or not. The diagnosis does not require a 12-lead ECG recording – a rhythm strip would be sufficient. You may want to discuss how diagnostic services are structured locally.
  • NOTES FOR PRESENTERS Rationale: This is THE key decision to be made in the care pathway for persistent AF – patient involvement is crucial. Patients in whom a rate-control or rhythm-control strategy is initiated should have their involvement in which treatment strategy is pursued recorded. As some patients with persistent AF will satisfy criteria for either an initial rate-control or rhythm-control strategy (for example, age over 65 but also symptomatic): - the indications for each option should not be regarded as mutually exclusive, and the potential advantages and disadvantages of each strategy should be explained to patients… - any co-morbidities that might indicate one approach rather than the other should be taken into account .
  • NOTES FOR PRESENTERS Please refer to the NICE guideline – pages 12, 13 and 14. The next 2 slides summarise which patients are most likely to benefit from either a rate-control or a rhythm-control strategy.
  • NOTES FOR PRESENTERS Specialist primary care clinics – GPs with Specialist Interest; consider access to ECG, echocardiography, anticoagulation and day case cardioversion, working closely with local cardiologists. Liaise with your local cardiac network – benefit from shared learning and support. You may want to take this opportunity to discuss how your organisation is working with your local cardiac network.
  • NOTES FOR PRESENTERS Rationale: Anticoagulation is effective and needs to be administered according to a formal assessment of stroke risk. Patients should be assessed for risk of stroke/thromboembolism and administered thromboprophylaxis according to the stroke risk stratification algorithm. This assessment and any antithrombotic therapy should be recorded.
  • NOTES FOR PRESENTERS Refer to the NICE guideline – page 47. The next slide shows the management recommendations.
  • NOTES FOR PRESENTERS For further details, refer to the NICE guideline – page 47.
  • NOTES FOR PRESENTERS Refer to NICE guideline – pages 22 and 23 In order to provide adequate thromboprophylaxis with minimal risk of bleeding, current clinical practice aims for a target INR of between 2.0 and 3.0; INRs higher than 3.0 are associated with increases in bleeding, and INRs lower than 2.0 are associated with increases in stroke risk.
  • NOTES FOR PRESENTERS Currently, there is sub-optimal use of thromboprophylaxis for AF, especially in the elderly. Sub-optimal use of thromboprophylaxis may also be due to patient factors, where some patients choose the option of ‘informed dissent’ and decline an effective treatment option. Consider offering patients alternative forms of INR monitoring, e.g. patient self-monitoring/self-adjusted therapy. Patient information, education and training will be required. Don’t forget to use the NICE Information for the Public.
  • NOTES FOR PRESENTERS Rationale: there is current over-prescription of digoxin for ventricular rate control, rather than more effective drugs. Patients who are prescribed digoxin as initial monotherapy for rate control should have the reason for this prescription recorded where it is not obvious (e.g. sedentary patient, presence of contraindication to alternatives).
  • NOTES FOR PRESENTERS In patients with permanent AF who need treatment for rate-control: - beta-blockers or rate-limiting calcium antagonists should be the preferred initial monotherapy in all patients In patients with permanent AF where monotherapy is inadequate: to control the heart rate during normal activities only, beta-blockers or rate-limiting calcium antagonists should be administered with digoxin to control the heart rate during both normal activities and exercise, rate-limiting calcium antagonists should be administered with digoxin
  • NOTES FOR PRESENTERS For further details, refer to the NICE guideline – page 27. Patients undergoing PCV are usually admitted to hospital
  • NOTES FOR PRESENTERS Please refer to the NICE guideline – page 16.
  • NOTES FOR PRESENTERS Refer to the NICE guideline – page 19.
  • NOTES FOR PRESENTERS For further details, refer to the NICE guideline – page 25. The commonest reason for referral for specialist investigation or intervention is failed medical therapy
  • NOTES FOR PRESENTERS This guideline is supported by a number of implementation tools, all of which are accessible via the NICE website.
  • NOTES FOR PRESENTERS The guideline is available in a number of formats. You can download them from the NICE website or order hard copies of the quick reference guide or information for the public by calling the NHS Response Line on 0870 1555 455. Please refer to the accompanying implementation advice for the policy context and useful links.
  • Ann Int Med Vol150 Is6 Pg396 F1

    1. 1. Atrial fibrillation June 2006
    2. 2. Changing clinical practice <ul><li>NICE guidelines are based on the best available evidence </li></ul><ul><li>The Department of Health asks NHS organisations to work towards implementing guidelines </li></ul><ul><li>Compliance will be monitored by the Healthcare Commission </li></ul>
    3. 3. Atrial fibrillation <ul><li>Atrial fibrillation (AF) is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation with consequent deterioration of atrial mechanical function </li></ul><ul><li>On the ECG, there is an absence of consistent P waves; instead there are rapid oscillations or fibrillatory waves that vary in size, shape and timing </li></ul>
    4. 4. Reproduced by kind permission of Ashford and St. Peter’s Hospitals NHS Trust
    5. 5. Several causes of AF <ul><li>Often caused by co-existing medical conditions – both cardiac and non-cardiac </li></ul><ul><li>Associated with increasing age, hypertension, heart failure, diabetes mellitus and valve disease </li></ul><ul><li>Dietary and lifestyle factors have also been associated with AF </li></ul><ul><li>Common after surgery, especially cardiothoracic operations </li></ul>
    6. 6. Classification of AF Established Not terminated Terminated but relapsed No cardioversion attempt Permanent (‘accepted’) Recurrent Not self-terminating Lasting >7 days or prior cardioversion Persistent Recurrent Spontaneous termination <7 days and most often <48 hours Paroxysmal May or may nor reoccur Symptomatic Asymptomatic Onset unknown Initial event (first detected episode) Pattern Clinical features Terminology
    7. 7. Need for this guideline <ul><li>AF is a significant risk factor for mortality, as well as stroke and other morbidities </li></ul><ul><li>AF is the commonest sustained cardiac arrhythmia </li></ul><ul><li>Too often, AF is detected only after the patient presents with serious complications of AF </li></ul><ul><li>AF incidence and prevalence increase with increasing age. With an increasingly elderly population, AF is likely to become more common </li></ul>
    8. 8. Commonest cardiac arrhythmia <ul><li>The prevalence of AF roughly doubles with each decade of age: from 0.5% at age 50 – 59 years to almost 9.0% at age 80 – 90 years </li></ul><ul><li>Present in 3 – 6% of acute hospital admissions </li></ul><ul><li>Prevalence of 4.7% of people aged 65 years or over in general practice </li></ul>
    9. 9. Prevalence of AF in the Renfrew-Paisley study Cohort of men and women aged 45 – 64 years (n = 15,406) Reproduced with permission of the BMJ Publishing Group from Stewart S et al, Heart 2001: 86:516-21
    10. 10. What needs to happen <ul><li>Opportunistic/targeted case detection including taking a manual pulse to detect AF </li></ul><ul><li>Accurate diagnosis of AF using an ECG </li></ul><ul><li>Further investigations and clinical assessment, including risk stratification for stroke/thromboembolism </li></ul><ul><li>Development of a management plan – rate-control, rhythm-control or referral </li></ul><ul><li>Antithrombotic therapy as appropriate </li></ul><ul><li>Follow-up and review </li></ul>
    11. 11. AF care pathway Primary/secondary/ emergency care Primary/secondary care Secondary/tertiary care The management and presentation of AF involves all healthcare settings Case detection Assessment Rate- control Rhythm- control Referral Follow-up Follow-up OR
    12. 12. Key priority – detection and diagnosis An ECG should be performed in all patients, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected Case detection Assessment Rate- control Rhythm- control Referral Follow-up Follow-up OR
    13. 13. Suggested actions <ul><li>People with undiagnosed AF can receive treatment sooner if opportunistic case finding is undertaken using manual pulse palpation </li></ul><ul><li>Promote opportunistic case detection and targeting of patients at increased risk: </li></ul><ul><li>Primary care: appropriate long-term condition registers, people aged >65 years, flu vaccination programme </li></ul><ul><li>Secondary care: A&E, outpatient clinics and wards, especially care of the elderly </li></ul>
    14. 14. Suggested actions <ul><li>Remember to use ECG to confirm diagnosis and the routine recording of ECG results </li></ul><ul><li>Review access to diagnostics – irrespective of how services are structured locally, easy access and rapid reporting are essential </li></ul><ul><li>Remember incentives and encourage practices to establish and maintain a practice-based AF register in line with the QOF 06/07 AF indicators </li></ul><ul><li>Consider establishing a PCT-led, community-based, rapid-access arrhythmia clinic </li></ul>
    15. 15. Key priority – choosing the most effective treatment <ul><li>Some patients with </li></ul><ul><li>persistent AF will satisfy </li></ul><ul><li>criteria for either an initial </li></ul><ul><li>rate- or rhythm-control </li></ul><ul><li>strategy </li></ul><ul><li>Indications for each </li></ul><ul><li>option are not mutually </li></ul><ul><li>exclusive </li></ul><ul><li>Involve the patient in the </li></ul><ul><li>treatment decision </li></ul><ul><li>Take comorbidities into </li></ul><ul><li>account </li></ul><ul><li>Antithrombotic therapy </li></ul><ul><li>should always be used </li></ul>Case detection Assessment Rate- control Rhythm- control Referral Follow-up Follow-up OR
    16. 16. Treatment for persistent AF <ul><li>Two main treatment strategies: </li></ul><ul><li>Rate-control involves the use of chronotropic drugs or electrophysiological/surgical interventions </li></ul><ul><li>Rhythm-control involves the use of electrical or pharmacological cardioversion for persistent AF, or suppression of recurrent (e.g. paroxysmal) AF </li></ul><ul><li>There is still the need for appropriate antithrombotic therapy if a rhythm-control strategy is chosen </li></ul>
    17. 17. Rate-control strategy <ul><li>Try rate control first for patients with persistent AF: </li></ul><ul><li>over 65 </li></ul><ul><li>with coronary artery disease </li></ul><ul><li>with contraindications to antiarrhythmic drugs </li></ul><ul><li>unsuitable for cardioversion </li></ul><ul><li>without congestive heart failure </li></ul>
    18. 18. Rhythm-control strategy <ul><li>Try rhythm-control first for patients with persistent AF: </li></ul><ul><li>who are symptomatic </li></ul><ul><li>who are younger </li></ul><ul><li>presenting for the first time with lone AF </li></ul><ul><li>secondary to a treated/corrected precipitant </li></ul><ul><li>with congestive heart failure </li></ul>
    19. 19. Suggested actions <ul><li>Liaise with your local cardiac network – benefit from shared learning and support. For example, some areas have established a primary care rapid access arrhythmia clinic and the provision of an arrhythmia care co-ordinator or an arrhythmia nurse specialist </li></ul><ul><li>Provide awareness raising and education sessions for healthcare professionals – don’t forget to include out-of-hours services </li></ul><ul><li>Develop, promote and disseminate quality patient information and decision aids for clinicians </li></ul>
    20. 20. Key priority – assess for risk of stroke and thromboembolism <ul><li>Use the ‘stroke risk </li></ul><ul><li>stratification algorithm’ to </li></ul><ul><li>assess risk of stroke and </li></ul><ul><li>thromboembolism </li></ul><ul><li>Use antithrombotic </li></ul><ul><li>therapy as appropriate </li></ul><ul><li>Initiate antithrombotic </li></ul><ul><li>therapy with minimal </li></ul><ul><li>delay in patients newly </li></ul><ul><li>diagnosed with AF </li></ul>Case detection Assessment Rate- control Rhythm- control Referral Follow-up Follow-up OR
    21. 21. Determine stroke/thromboembolic risk <ul><li>High risk: </li></ul><ul><li>Previous ischaemic stroke/TIA or thromboembolic event </li></ul><ul><li>Age >75 with hypertension, diabetes or vascular disease </li></ul><ul><li>Clinical evidence of valve disease, heart failure, or impaired left ventricular function on echocardiography </li></ul><ul><li>Moderate risk : </li></ul><ul><li>Age >65 with no high risk factors </li></ul><ul><li>Age <75 with hypertension, diabetes or vascular disease </li></ul><ul><li>Low risk: </li></ul><ul><li>Age <65 with no moderate or high risk factors </li></ul>Patients with AF
    22. 22. Determine stroke/thromboembolic risk High risk Moderate risk Low risk Consider anticoagulation Consider anticoagulation or aspirin Aspirin 75 to 300 mg/day if no contraindications Contraindications to warfarin? Warfarin, target INR = 2.5 (range 2.0 to 3.0) Reassess risk stratification whenever individual risk factors are reviewed NO YES Patients with AF
    23. 23. Anticoagulation <ul><li>Assessment of bleeding risk should be part of the clinical assessment of AF patients prior to starting anticoagulation </li></ul><ul><li>Antithrombotic benefits and potential bleeding risks of long-term coagulation should be explained and discussed with the patient </li></ul><ul><li>Aim for a target INR of between 2.0 and 3.0 </li></ul><ul><li>Forms of monitoring include point of care or near patient testing and patient self-monitoring </li></ul>
    24. 24. Suggested actions <ul><li>Review anticoagulation services locally </li></ul><ul><li>Remember incentives for anticoagulation monitoring and near patient testing, e.g. QOF 06/07 and National Enhanced Services </li></ul><ul><li>Provide awareness raising and education sessions - emphasise stroke prevention and promote the use of the stroke risk stratification algorithm </li></ul><ul><li>Consider integrating risk stratification into computerised patient management software </li></ul><ul><li>Ensure provision of quality patient information </li></ul>
    25. 25. Key priority – optimise pharmacological management In patients with permanent AF, who need treatment for rate-control: – beta-blockers or rate-limiting calcium antagonists should be the preferred initial monotherapy in all patients – digoxin should only be considered as monotherapy in predominantly sedentary patients Case detection Assessment Rate- control Rhythm- control Referral Follow-up Follow-up OR
    26. 26. Treatment for permanent AF <ul><li>The aim of heart rate control is to: </li></ul><ul><li>minimise symptoms associated with excessive heart rates </li></ul><ul><li>prevent tachycardia-associated cardiomyopathy </li></ul><ul><li>Digoxin monotherapy should only be useful for older, sedentary patients </li></ul><ul><li>Perform a risk – benefit assessment to inform the decision of whether or not to give antithrombotic therapy </li></ul>
    27. 27. Suggested actions <ul><li>Work with local Drugs and Therapeutics Committees and prescribing advisors to review and update prescribing formularies </li></ul><ul><li>Emphasise clinically effective alternatives to digoxin to PCT prescribing advisors and prescribing leads </li></ul><ul><li>Provide awareness raising and updating sessions for local primary and secondary care healthcare professionals </li></ul>
    28. 28. Cardioversion <ul><li>Cardioversion is performed as part of a rhythm-control treatment strategy </li></ul><ul><li>There are two types of cardioversion: electrical (ECV) and pharmacological (PCV) </li></ul><ul><li>Cardioversion of AF is associated with increased risk of stroke in the absence of antithrombotic therapy </li></ul><ul><li>Not all attempts at ECV or PCV are successful </li></ul><ul><li>Patient choice is important </li></ul>
    29. 29. Treatment for paroxysmal AF <ul><li>Patients with paroxysmal AF can be highly symptomatic </li></ul><ul><li>Three main aims of treatment for paroxysmal AF are to: </li></ul><ul><li>suppress paroxysms of AF and maintain sinus rhythm </li></ul><ul><li>control heart rate during paroxysms of AF </li></ul><ul><li>prevent complications </li></ul><ul><li>Treatment strategies include out-of-hospital initiation of antiarrhythmic drugs: ‘pill in the pocket’ approach </li></ul><ul><li>Patients with paroxysmal AF carry the same risks of stroke and thromboembolism as those with persistent AF </li></ul>
    30. 30. Acute-onset AF <ul><li>Acute-onset AF requires immediate hospitalisation and urgent intervention </li></ul><ul><li>Those at highest risk have a ventricular rate greater than 150 bpm, ongoing chest pain or critical perfusion </li></ul>
    31. 31. Follow-up and referral <ul><li>Follow-up after cardioversion should take place at 1 month, and the frequency of subsequent reviews should be tailored to the patient </li></ul><ul><li>Reassess the need for anticoagulation at each review </li></ul><ul><li>Referral for further specialist intervention should be considered in patients: </li></ul><ul><li>in whom pharmacological therapy has failed </li></ul><ul><li>with lone AF </li></ul><ul><li>with ECG evidence of any underlying electrophysiological disorder </li></ul>
    32. 32. Costs and savings <ul><li>Main elements identified as: </li></ul><ul><li>costs incurred due to increased use of ECG to confirm diagnosis </li></ul><ul><li>increases in the use of anticoagulants in those with AF, which includes: costs of additional anticoagulant services and of major bleeds incurred, and savings resulting from strokes and deaths avoided </li></ul>
    33. 33. Access tools online <ul><li>Costing tools </li></ul><ul><ul><li>costing report </li></ul></ul><ul><ul><li>costing template </li></ul></ul><ul><li>Audit criteria </li></ul><ul><li>Implementation advice </li></ul><ul><li>Available from: </li></ul>
    34. 34. Access the guideline online <ul><li>Quick reference guide – a summary </li></ul><ul><li>NICE guideline – all of the recommendations </li></ul><ul><li>Full guideline – all of the evidence and rationale </li></ul><ul><li>Information for the public – a plain English version </li></ul>