Cg36 atrial fibrillation - quick reference guide

Quick reference guide
Atrial fibrillation
NICE clinical guideline 36Developed by the National Collaborating Centre for Chronic Conditions Atrial fibrillation
Contents
Patient-centred care
Key priorities for implementation
Atrial fibrillation care pathway
Case finding and ECG diagnosis
Echocardiography
Treatment strategy decision tree
Stroke risk stratification and thromboprophylaxis
Treatments for AF
Rhythm-control for persistent AF, including cardioversion Rate-control for persistent and permanent AF Haemodynamically unstable and acute-onset AF Referral for specialist intervention
Implementation
Further information
National Institute for
Health and Clinical Excellence
MidCity Place
National Institute for Health and Clinical Excellence, June 2006. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by orfor commercial organisations, or for commercial purposes, is allowed without the express written This guidance is written in the following context
This guidance represents the view of the Institute, which was arrived at after careful consideration
of the evidence available. Healthcare professionals are expected to take it fully into account when
exercising their clinical judgement. The guidance does not, however, override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances
of the individual patient, in consultation with the patient and/or guardian or carer.
Atrial fibrillation
Patient-centred care
Treatment and care should take into account patients’ individual needs and preferences. Goodcommunication is essential, supported by evidence-based information, to allow patients to reachinformed decisions about their care. Carers and relatives should have the chance to be involved indiscussions unless the patient thinks it inappropriate.
Key priorities for implementation
The following recommendations have been identified as priorities for implementation.
Identification and diagnosis
An electrocardiogram (ECG) should be performed in all patients, whether symptomatic or not, in whom atrial fibrillation (AF) is suspected because an irregular pulse has been detected.
Treatment for persistent AF
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 before agreeingwhich to adopt – any comorbidities that might indicate one approach rather than the other should be taken – irrespective of whether a rate-control or rhythm-control strategy is adopted in patients with persistent AF, appropriate antithrombotic therapy should be used.
Treatment for permanent AF
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 – digoxin should only be considered as monotherapy in predominantly sedentary patients.
Antithrombotic therapy
In patients with newly diagnosed AF for whom antithrombotic therapy is indicated (see page 8),such treatment should be initiated with minimal delay after the appropriate management ofcomorbidities.
The stroke risk stratification algorithm (see page 7) should be used in patients with AF to assesstheir risk of stroke and thromboembolism, and appropriate thromboprophylaxis given.
NICE clinical guideline 36
Atrial fibrillation
Atrial fibrillation care pathway
Continued AF
Sinus rhythm
1Further management to include rate- or rhythm-control treatment strategy and appropriate antithrombotic therapy based onstroke risk stratification model.
2Further follow-up for coexisting conditions and assessment for ongoing anticoagulation.
NICE clinical guideline 36
Atrial fibrillation
Case finding and ECG diagnosis
Perform manual pulse palpation to assess for an irregular pulse indicating underlying AF inpatients who present with breathlessness or dyspnoea, palpitations, syncope or dizziness, chestdiscomfort, or stroke/transient ischaemic attack (TIA). Perform an ECG in all patients, whether symptomatic or not, with an irregular pulse in whom AFis suspected. Where you suspect paroxysmal AF that has not been detected by standard ECG recording:– use a 24-hour ambulatory ECG monitor where you suspect asymptomatic episodes or where – use an event recorder ECG where symptomatic episodes are more than 24 hours apart. Echocardiography
Perform transthoracic echocardiography (TTE):– if a baseline echocardiogram is important for long-term management (such as in younger – if you are considering a rhythm-control strategy that includes electrical or pharmacological – if you suspect underlying structural or functional heart disease (failure or murmur) that would influence management, such as choice of antiarrhythmic drug – where needed to help with stratifying stroke risk for antithrombotic therapy, but only where clinical evidence is needed of left ventricular (LV) dysfunction or valve disease.
Do not routinely use TTE for further stroke risk stratification when you have already established
the need for anticoagulation therapy using appropriate clinical criteria.
Perform transoesophageal echocardiography (TOE):– when TTE has shown an abnormality such as valve disease that needs further assessment– where you need to exclude cardiac abnormalities and TTE is technically difficult or of – if you are considering TOE-guided cardioversion.
NICE clinical guideline 36
Atrial fibrillation
Treatment strategy decision tree
Further investigations and clinical assessment including risk stratification for stroke/thromboembolism Try rhythm-control first for patients
Try rate-control first for patients with
with persistent AF:
persistent AF:
presenting for the first time with lone AF – explain the advantages and disadvantages of each strategy to the patient before you decide which – take into account comorbidities when deciding which to use– use appropriate antithrombotic therapy. For rhythm-control, see pages 11 and 15. 3Patients unsuitable for cardioversion include those with: contraindications to anticoagulation; structural heart disease (e.g. large left atrium >5.5 cm, mitral stenosis) that precludes long-term maintenance of sinus rhythm; a long duration of AF (usually>12 months); a history of multiple failed attempts at cardioversion and/or relapses, even with concomitant use of antiarrhythmicdrugs or non-pharmacological approaches; an ongoing but reversible cause of AF (e.g. thyrotoxicosis).
NICE clinical guideline 36
Atrial fibrillation
Stroke risk stratification and thromboprophylaxis
Stroke risk stratification
High risk
Moderate risk
disease or heart failure, orimpaired LV function onechocardiography5 1 Note that risk factors are not mutually exclusive, and are additive to each other in producing a composite risk. Since the
incidence of stroke and thromboembolic events in patients with thyrotoxicosis appears similar to that in patients with otheraetiologies of AF, antithrombotic treatments should be chosen based on the presence of validated stroke risk factors.
2 Owing to lack of sufficient clear-cut evidence, treatment may be decided on an individual basis, and the physician must
balance the risks and benefits of warfarin versus aspirin. As stroke risk factors are cumulative, warfarin may, for example, beused in the presence of two or more moderate stroke risk factors. Referral and echocardiography may help in cases ofuncertainty.
4Coronary artery disease or peripheral artery disease.
5An echocardiogram is not needed for routine assessment, but refines clinical risk stratification in the case of moderate or severeLV dysfunction and valve disease.
NICE clinical guideline 36
Atrial fibrillation
Thromboprophylaxis
Use the stroke risk stratification algorithm to assess stroke and embolism risk in patients with AF, andgive appropriate thromboprophylaxis.
Reconsider stroke risk stratification whenever reviewing individual risk factors. Where it is indicated by stroke risk stratification, begin antithrombotic therapy with minimal delay inall patients with newly diagnosed AF, after comorbidities have been appropriately managed. Explain to and discuss with patients both the antithrombotic benefits and the potential bleeding risksof long-term anticoagulation. Assess bleeding risk as part of clinical assessment before starting a patient on anticoagulation therapy.
Pay particular attention to patients:– over 75– taking antiplatelet drugs (such as aspirin or clopidogrel) or non-steroidal anti-inflammatory drugs– on multiple other drug treatments– with uncontrolled hypertension– with a history of bleeding (such as peptic ulcer or cerebral haemorrhage)– with a history of poorly controlled anticoagulation therapy.
Before cardioversion, maintain patients on therapeutic anticoagulation with warfarin (INR 2.5, range 2.0 to 3.0) for at least 3 weeks. After successful cardioversion, maintain patients on therapeutic anticoagulation with warfarin (INR 2.5, range 2.0 to 3.0) for at least 4 weeks. If cardioversion cannot be postponed for 3 weeks:– give heparin before cardioversion – give warfarin for at least 4 weeks after cardioversion. After cardioversion, continue anticoagulation long term in patients with a high risk of AF recurrenceor where it is recommended by the stroke risk stratification algorithm (see page 7). Factors indicatinga high risk of AF recurrence include:– a history of failed cardioversion attempts– mitral valve disease, LV dysfunction or enlarged left atrium. Anticoagulation is not required when cardioversion successfully restores sinus rhythm in a patient withAF of confirmed duration of less than 48 hours. Give patients with atrial flutter or asymptomatic AF the same antithrombotic therapy as thosewith symptomatic AF. NICE clinical guideline 36
Atrial fibrillation
When deciding whether or not to give antithrombotic therapy for permanent AF, perform arisk–benefit assessment in discussion with the patient.
Where antithrombotic therapy is given:– the most effective treatment is adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0)– where warfarin is inappropriate, give aspirin (75 to 300 mg/day)– if warfarin is appropriate, do not coadminister aspirin purely for thromboprophylaxis, as it provides Do not base decisions on the need for antithrombotic therapy for paroxysmal AF on the frequency orduration of symptomatic or asymptomatic paroxysms. Perform appropriate risk stratification, as forpermanent AF (see algorithm on page 7).
Antithrombotic therapy for acute-onset AF In patients with acute AF who are receiving no, or only subtherapeutic, anticoagulation therapy:– start heparin at initial presentation, unless contraindicated– continue heparin until a full risk assessment has been made and appropriate antithrombotic therapy started, based on risk stratification (see algorithm on page 7). In patients with a confirmed diagnosis of acute AF (less than 48 hours since onset), use oralanticoagulation if:– stable sinus rhythm is not restored within the 48-hour period following onset or– there are other risk factors for AF recurrence6 or– it is recommended by the stroke risk stratification algorithm (see page 7). Where the precise time since the onset of acute AF is uncertain, use oral anticoagulation for acute AF, as for persistent AF (see page 8). Where a patient with acute AF is haemodynamically unstable, begin emergency treatment assoon as possible. Do not delay emergency intervention in order to begin anticoagulationtreatment first. 6 Risk factors include: a history of failed cardioversion attempts; structural heart disease (mitral valve disease, LV dysfunction orenlarged left atrium); prolonged history of AF (greater than 12 months); previous recurrences of AF.
NICE clinical guideline 36
Atrial fibrillation
Antithrombotic therapy for acute stroke/TIA in patients with AF7 For acute stroke in patients with AF:– manage any uncontrolled hypertension before starting antithrombotic therapy – perform CT or MRI to exclude cerebral haemorrhage: where there is haemorrhage, do not give anticoagulation therapy where there is no haemorrhage, begin anticoagulation therapy after 2 weeks – delay anticoagulation therapy where there is a large cerebral infarction. For acute TIA in patients with AF:– perform CT or MRI to exclude recent cerebral infarction or haemorrhage– in the absence of either, begin anticoagulation therapy as soon as possible. Antithrombotic therapy following stroke/TIA in patients with AF Give warfarin as the most effective thromboprophylactic agent. Do not give aspirin or dipyridamole as thromboprophylactic agents unless indicated for comorbiditiesor vascular disease. Only begin warfarin treatment after treating relevant comorbidities such as hypertension andassessing the risk–benefit ratio. Self-monitoring for long-term anticoagulation Consider self-monitoring for patients with AF who require long-term anticoagulation if they wouldprefer it and the following criteria are met:– the patient (or a designated carer) is physically and cognitively able to perform the self-monitoring – there is an adequate supportive educational programme to train patients and/or carers– the patient’s ability to self-manage is reviewed regularly– the equipment is checked regularly using a quality-control programme. 7 NICE is developing a clinical guideline on the diagnosis and management of stroke (publication expected 2008).
NICE clinical guideline 36
Atrial fibrillation
Treatments for AF
Rhythm-control for persistent AF, including cardioversion
1 Patients with persistent
2 Based on stroke risk
stratification algorithmand cardioversiontreatment algorithm.
3 An antiarrhythmic drug
whom a precipitant(such as chest infection, corrected andcardioversion has beenperformed successfully.
4 Routine follow-up to
of sinus rhythm shouldtake place at 1 and 5 Class 1c agents
8 If rhythm-control fails, consider the patient for rate-control strategy, or specialist referral for those with lone AF or ECG evidence of underlying electrophysiological disorder (e.g. Wolff–Parkinson–White [WPW] syndrome).
NICE clinical guideline 36
Atrial fibrillation
1 Perform TTE examination before
rhythm-control treatmentstrategy involving cardioversion.
Patient scheduled for elective cardioversion 2 Also consider patient preference
advantages and disadvantagesof each option.
3 Administer at least 3 weeks’
cardioversion, depending onpreference, contraindications 4 High risk of cardioversion
5 Intravenous amiodarone as
6 As determined by the stroke
AF recurrence. Patients with ahistory of AF > 12 months, recurrence are at a higher riskof AF recurrence.
7 Anticoagulation should be
NICE clinical guideline 36
Atrial fibrillation
See ‘Antithrombotic therapy for persistent AF’ on page 8 for recommendations onthromboprophylaxis before and after cardioversion.
After successful cardioversion of AF, arrange routine follow-up at 1 month and 6 months to assessmaintenance of sinus rhythm. At the 1-month follow-up, tailor the frequency of subsequent reviews to the individual patient, takinginto account comorbidities and concomitant drug therapies. At each review, take the opportunity to reassess the need for, and the risks and benefits of, continuedanticoagulation. If a patient has relapsed into AF at follow-up, fully re-evaluate their need for a rate-control or rhythm-control strategy.
If patients remain in sinus rhythm at 6 months and have no other need for hospital follow-up,discharge from secondary care and arrange an appropriate management plan with their GP. Advise patients to seek medical attention if their symptoms recur.
NICE clinical guideline 36
Atrial fibrillation
Rate-control for persistent and permanent AF
1 Patients with permanent
persistent AF who have beenselected for a rate-controltreatment strategy.
2 Based on stroke risk
3 Target a resting heart rate of
less than 110 bpm (inactive),200 minus age (active).
Yes (during
activities)
exercise)
4 Referral for further specialist
electrophysiological disorder(e.g. WPW syndrome) or wherepharmacological therapy hasfailed.
NICE clinical guideline 36
Atrial fibrillation
Rhythm-control for paroxysmal AF
1 Based on stroke risk stratification
2 Consider a ’pill-in-the-pocket’
strategy for those who i) have nohistory of LV dysfunction, or valvular episodes of paroxysmal AF,iii) have a systolic blood pressure 3 Sotalol to be progressively
4 Referral for further specialist
especially in those with lone AF orECG evidence of an underlyingelectrophysiological disorder (e.g.
WPW syndrome) or wherepharmacological therapy has failed.
Keep patients who are on long-term medication for paroxysmal AF under review to assess the needfor continued treatment and the development of any adverse effects.
NICE clinical guideline 36
Atrial fibrillation
Haemodynamically unstable and acute-onset AF
Emergency treatment for haemodynamically unstable AF 1 Diagnosis to be confirmed by
2 Any emergency intervention
No (or not
3 Where urgent pharmacological rate-
blockers or rate-limiting calciumantagonists, or ii) amiodarone, wherebeta-blockers or calcium antagonistsare contraindicated or ineffective.
4 Where there is a delay in organising
electrical cardioversion, intravenousamiodarone should be used. Inthose with known WPW syndrome,flecainide is an alternative(atrioventricular node-blockingagents such as diltiazem, verapamilor digoxin should not be used).
Antithrombotic therapy for acute-onset AF See section on ‘Antithrombotic therapy for acute-onset AF’ on page 9.
NICE clinical guideline 36
Atrial fibrillation
Post-operative AF
In patients undergoing cardiothoracic surgery:– reduce the risk of post-operative AF by giving one of: Patients undergoing cardiac surgery who are on pre-existing beta-blocker therapy should continue thistreatment unless contraindications develop (such as post-operative bradycardia or hypotension). For post-operative AF after cardiothoracic surgery, use a rhythm-control strategy as the firstmanagement option, unless contraindicated.
Manage post-operative AF after non-cardiothoracic surgery in the same way as acute-onset AF withany other precipitant. When preventing and managing post-operative AF, use antithrombotic therapy as appropriate, andcorrect identifiable causes such as electrolyte imbalance or hypoxia. Referral for specialist intervention
Consider referral for further specialist intervention (such as pulmonary vein isolation, pacemakertherapy, arrhythmia surgery, atrioventricular junction catheter ablation or use of atrial defibrillators) for patients: – in whom pharmacological therapy has failed– with lone AF– with ECG evidence of any underlying electrophysiological disorder such as Wolff–Parkinson–White Explain and discuss the reasons for such referral with the patient. NICE clinical guideline 36
Atrial fibrillation
Implementation
Further information
Quick reference guide
performance of NHS organisations in meeting core This quick reference guide to the Institute’s guideline on atrial fibrillation contains the Department of Health in ‘Standards for better key priorities for implementation, summaries health’ issued in July 2004. Implementation of of the guidance, and notes on implementation. clinical guidelines forms part of the developmental standard D2. Core standard C5 says that national agreed guidance should be taken into account www.nice.org.uk/CG036distributionlist).
NICE has developed tools to help organisations For printed copies, phone the NHS Response Line on 0870 1555 455 and quote reference number NICE guideline
Slides highlighting key messages for local The NICE guideline, ’Atrial fibrillation: the management of atrial fibrillation’, is available – Costing report to estimate the national The NICE guideline contains the following sections: Key priorities for implementation; – Costing template to estimate the local costs 4 Research recommendations; 5 Other versions of this guideline; 6 Related NICE guidance; guidance into practice and national initiatives 7 Review date. It also gives details of the grading scheme for the evidence and recommendations,the Guideline Development Group and the Audit criteria to monitor local practice. Guideline Review Panel, and technical detail on the criteria for audit.
Full guideline
The full guideline includes the evidence on
which the recommendations are based, in addition
to the information in the NICE guideline. It is
published by the National Collaborating Centre
for Chronic Conditions. It is available from
www.rcplondon.ac.uk/ncc-cc, from the website of
the National Library for Health (www.nlh.nhs.uk),
and from www.nice.org.uk/CG036fullguideline
NICE clinical guideline 36
Atrial fibrillation
Information for the public
Review date
NICE has produced a version of this guidance for The process of reviewing the evidence is expected people with atrial fibrillation, their families and to begin 4 years after the date of issue of this carers, and the public, which is available from guideline. Reviewing may begin before this if significant evidence that affects the guidelinerecommendations is identified. The updated For printed copies, phone the NHS Response Line guideline will be available within 2 years of the on 0870 1555 455 and quote reference number Related guidance
Radiofrequency ablation for atrial fibrillation inassociation with other cardiac surgery. NICEinterventional procedure guidance no. 121(2005). Available fromwww.nice.org.uk/IPG121 Cryoablation for atrial fibrillation in associationwith other cardiac surgery. NICE interventionalprocedure guidance no. 122 (2005). Availablefrom www.nice.org.uk/IPG122 Microwave ablation for atrial fibrillation inassociation with other cardiac surgery. NICEinterventional procedure guidance no. 123(2005). Available fromwww.nice.org.uk/IPG123 Percutaneous radiofrequency ablation for atrialfibrillation. NICE interventional procedureguidance no. 168 (2006). Available fromwww.nice.org.uk/IPG168 High-intensity focused ultrasound for atrialfibrillation as an associated procedure withother cardiac surgery. NICE interventionalprocedure guidance no. 175 (2006). Availablefrom www.nice.org.uk/IPG175 For information about NICE guidance that hasbeen issued or is in development, see the website(www.nice.org.uk).
NICE clinical guideline 36
National Institute for
Health and Clinical Excellence

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