New Atrial Fibrillation/Flutter Pathway and GRASP Tool

1. New Atrial Fibrillation/Flutter Pathway and GRASP Tool Kay Elliott British Heart Foundation Arrhythmia Nurse Specialist Dorset County Hospital NHS Foundation Trust

2. To Discuss: Primary/Secondary Care Pathway for new onset atrial fibrillation/Flutter GRASP* Tool – Identifying and risk stratifying chronic AF/Flutter in primary care *Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation in Patients in Primary Care Aim

3. New Onset Atrial Fibrillation or Flutter Is the patient acutely unwell? No Yes Primary Care START WARFARIN AND RATE CONTROL (see box A) Issue patient education leaflet: ‘Atrial Fibrillation and Warfarin’. Attached, also available: www.patient.co.uk/showdoc/23068883 Admit to Hospital NEED FURTHER ADVICE? CONTACT: BHF ARRHTYHMIA NURSE: 01305 254920 • Box A: Rate control • First Line: • 1.Beta-blocker (e.g. Bisoprolol) or a rate limiting calcium antagonist (e.g. Diltiazem), if beta-blocker contraindicated • 2.Digoxin – additional to optimise rate control, where required. As monotherapy only in predominantly sedentary patients. • NICE (2006) Persistent Fax referral to Rapid Access Atrial Fibrillation/Flutter Clinic. (Form attached. Also available on Dorset County Hospital intranet or by contacting BHF Arrhythmia Nurse) Paroxysmal Refer to cardiology team in the usual way. Rapid Access Atrial Fibrillation/Flutter Clinic Cardiologist

4. Rapid Access • Atrial Fibrillation/Flutter Clinic • ONE STOP APPOINTMENT • (WITHIN 4 WEEKS OF REFERRAL) • ECHO AND ECG • BHF ARRHYTHMIA NURSE CLINIC: • qReview history, symptoms, test and examination results • qPatient education • qAgree treatment plan: DC Cardioversion or Rate Control • qArrange ongoing follow-up, where required Cardiologist input into RAAF clinic. Also patients referred for DC Cardioversion from cardiology clinic or in-patient stay. Cardiologist BHF Arrhythmia Nurse Specialist: Arrange DC Cardioversion Primary Care Manage long-term warfarin and rate-control

5. Prepare for DC Cardioversion: Weekly INR (Target 2.5-3.0), must have INR >2.0 for four full weeks prior to DC Cardioversion (see next page) • DC Cardioversion – BHF ARRHYTHMIA NURSE/DAY SURGERY UNIT • Procedure • Review of medications and treatment pre-discharge (Cardiology Specialist Registrar and BHF Arrhythmia Nurse) • Review with BHF Arrhythmia Nurse at 4 weeks, ongoing treatment plan • N.B. Maintaining a therapeutic INR during the four weeks post successful DC Cardioversion is important in terms of stroke risk reduction.

6. 4 Weeks post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse Is the Patient in Sinus Rhythm? Yes/No YES NO Cardiology Review Patient remains symptomatic despite adequate rhythm or rate control. Other cardiac complications are revealed. Depending on clinical indications and patient preference either: Re-attempt DC Cardioversion with amiodarone cover Refer for ablation therapy Rate control/Warfarin (primary Care) Refer to Electrophysiology centre for ablation therapy, if appropriate 6 months post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse Is the Patient in Sinus Rhythm?

7. 6 months post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse Is the Patient in Sinus Rhythm? Yes No Depending on clinical indications and patient preference either: Re-attempt DC Cardioversion with amiodarone cover Referral for ablation therapy Rate control/Warfarin (primary Care) Discharged to primary care and advised to seek medical attention if symptoms recur

8. Prevalence of AF in primary care is 1.2% (England) 12,500 strokes per year are thought to be directly attributable to AF Estimated annual cost of maintaining one patient on warfarin: £383 Estimated cost per stroke due to AF is £11,900 in the first year post stroke occurrence Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF)

9. NICE estimate that 46% of patients that should be on warfarin are not receiving it Warfarin reduces risk of stroke by 64% in atrial fibrillation Aspirin reduces the risk of stroke by 22% in atrial fibrillation Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF)

10. The GRASP-AF Tool facilitates audit to identify high risk AF patients not on warfarin It is a MIQUEST IT tool that can be freely downloaded from www.improvement.nhs.uk Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF)

11. It can be used to identify patients in atrial fibrillation with a CHADS2 score of >1 The final report can exclude those with recorded contraindications to warfarin Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP – AF)

12. Identify new atrial fibrillation/flutter – (include routine pulse checks at all appropriate consultations) Refer to RAAF clinic (persistent), consultant (paroxysmal) or admit if acutely unwell Rate Control and warfarin/aspirin in primary care Patients will be reviewed with echocardiogram and specialist clinic/consultant input GRASP-AF Tool – opportunity to ensure practice population on evidence based stroke prophylaxis in atrial fibrillation – Potential to reduce morbidity/mortality and health costs Summary

13. Over to You – Any Questions?