New Atrial Fibrillation/Flutter Pathway and GRASP Tool

Kay Elliott British Heart Foundation

Arrhythmia Nurse Specialist

Dorset County Hospital NHS Foundation Trust

AimAim

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

Admit to Hospital   

Primary CareSTART WARFARIN AND RATE CONTROL (see box A)

Issue patient education leaflet:‘Atrial Fibrillation and Warfarin’. Attached, also available: www.patient.co.uk/showdoc/23068883

ParoxysmalRefer to cardiology team in the usual way.

 Cardiologist

PersistentFax referral to Rapid Access Atrial Fibrillation/Flutter Clinic. (Form attached. Also available on Dorset County Hospital intranet or by contacting BHF Arrhythmia Nurse)

 NEED FURTHER ADVICE? CONTACT:BHF ARRHTYHMIA NURSE: 01305 254920 

Box A: Rate control First Line:1. 1. Beta-blocker (e.g. Bisoprolol)

or a rate limiting calcium antagonist (e.g. Diltiazem), if beta-blocker contraindicated

2. 2. Digoxin – additional to optimise rate control, where required. As monotherapy only in predominantly sedentary patients.

NICE (2006)

New Onset Atrial Fibrillation or FlutterIs the patient acutely unwell?

Yes No 

                   

 

  Rapid Access Atrial

Fibrillation/Flutter Clinic

Rapid Access Atrial Fibrillation/Flutter Clinic

ONE STOP APPOINTMENT (WITHIN 4 WEEKS OF REFERRAL)  

1. ECHO AND ECG2. BHF ARRHYTHMIA NURSE CLINIC:

       Review history, symptoms, test and examination results

       Patient education       Agree treatment plan: DC Cardioversion or

Rate Control       Arrange ongoing follow-up, where required

Cardiologist input into RAAF clinic. Also patients referred for DC Cardioversion from cardiology clinic or in-patient stay.

 Cardiologist

Primary CareManage long-term warfarin and rate-control

BHF Arrhythmia Nurse Specialist:Arrange DC Cardioversion

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.

4 Weeks post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse

Is the Patient in Sinus Rhythm?

Cardiology Review

Patient remains symptomatic despite adequate rhythm or rate control.

Other cardiac complications are revealed.

Depending on clinical indications and patient preference either:

1. Re-attempt DC Cardioversion with amiodarone cover

2. Refer for ablation therapy3. Rate control/Warfarin (primary Care)

YES NO

Refer to Electrophysiology centre for ablation therapy, if appropriate

Yes/No

6 months post procedure Follow-Up (NICE, 2006) BHF Arrhythmia Nurse

Is the Patient in Sinus Rhythm?

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:

1. Re-attempt DC Cardioversion with amiodarone cover

2. Referral for ablation therapy3. Rate control/Warfarin (primary

Care)

Discharged to primary care and advised to seek medical attention if symptoms recur

Guidance on Risk Assessment for Guidance on Risk Assessment for Stroke Prevention in Atrial Stroke Prevention in Atrial Fibrillation (GRASP – AF)Fibrillation (GRASP – AF)

• 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 Guidance on Risk Assessment for Stroke Prevention in Atrial Stroke Prevention in Atrial Fibrillation (GRASP – AF)Fibrillation (GRASP – AF)

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 Guidance on Risk Assessment for Stroke Prevention in Atrial Stroke Prevention in Atrial Fibrillation (GRASP – AF)Fibrillation (GRASP – AF)

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 Guidance on Risk Assessment for Stroke Prevention in Atrial Stroke Prevention in Atrial Fibrillation (GRASP – AF)Fibrillation (GRASP – AF)

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

SummarySummary

• 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

Over to You – Any Questions?Over to You – Any Questions?