Barns Medical Practice Service Specification: Atrial Fibrillation
DEVELOPED March 2015 REVIEW DATE March 2017
Introduction
Atrial fibrillation (AF) is a condition where the heart rhythm becomes completely irregular. This may be permanent (been constant and have persisted for several months) or paroxysmal (come and go, normally with the heart being regular for most of the time). Sometimes AF can have a treatable cause eg an overactive thyroid and sometimes can be a result of an important heart problem such as valve disease but often it occurs in hearts that are otherwise completely normal.
It is important for two main reasons. Firstly, once the heart rate in AF rises above a rate of about 90 beats per minute (bpm), the heart starts to pump less efficiently and patients may experience symptoms (see below)and secondly AFincreases the risk of stroke. The object of treatment of persistent AF is to prevent the patient having symptoms and minimising the risk of stroke.
Diagnosis
The symptoms of AF arebreathlessness, palpitation(awareness of the heart beating fast and irregularly), dizziness and chest pain. All patients complaining of these symptoms shoud have their pulse checked. Finding the pulse to be irregular should raise the suspicion of AF and equally, finding the pulse to be completely regular makes the diagnosis unlikely unless it is very fast >120 bmp. Considration of the rhythm and rate of the pulse should be given whenever the blood pressure (BP) is measured and, indeed, the BPshould not be measured using an electronic BP monitor until the pulse has been confirmed as regular.
If AF is suspected a 12 lead electrocardiograph (ECG) should be arranged, urgently, if the patient is symptomatic. A doctor, or other qualified person should report the ECG and the diagnosis should not be made exclusively on the automatic machine generated diagnosis. Where the diagnosis is confirmed, the heart should be, or have been, examined for murmurs and the thyroid function test should be checked. If murmurs are found, these should be evaluated by referral either for open access echocardiography or to cardiology outpatient clinic.
The CHADS2 score which quantifies the risk of stroke should be determined. This is a points based system where the appropriate points are assigned to the following conditions
ConditionPoints
CCongestive heart failure1
HHypertension1
AAge > 75 years1
DDiabetes Mellitus1
S2Prior Stroke or TIA2
Treatment
Many patients who have no symptoms will not need any treatment for their heart rate or rhythm. Where the patient has symptoms, the main strategy for treatment is “rate control” using beta-blockers such as bisoprolol or atenolol with the objective of keeping the pulse rate below 90. Where beta-blockers are contraindicated, diltiazem or verapamil can be used. If “rhythm control” is considered desirable e.g. in symptomatic paroxysmal AF, digoxin or amiodarone may be tried.
Patients with a CHADS2 score of 1 or greater should be offered oral anticoagulation with warfarin. Very low risk patients with a score of 0 should not be offered either warfarin or antiplatelet therapy as aspirin is considered to carry the same risk as warfarin but not the same benefit of preventing 6 out of 10 strokes.
Regular Review
As with all long term conditions, all patients with AF will be offered an annual review in the month of their birthday. If they fail to attend within a month this invitation will be repeated twice more at monthly intervals.
The annual review should be carried out by a prescriber. The following will be undertaken
Symptomatic enquiry: Breathlessness, chest pain, palpitation & dizziness
Pulse assessment for rhythm and rate.
BP using a manual sphygmomanometer
CHADS2 score should be updated and the need for anticoagulation assessed.
Medication reviewed for concordance and side effects.
Resources for Staff and or Patients
Practice specific information: None
Internet information
Staff involved and training required
HCA: ECG performance, blood sampling at diagnosis
Independent prescribers: If trained in ECG assessment of AF and cardiac auscultation diagnosis annual review.
Advertising of service to patients
Details of this service will be available on the practice website.
Patients will be advised of the service at the point of diagnosis.