DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)

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1 DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic therapy An electrocardiogram (ECG) should be performed in all patients, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected Rate control is usually the most appropriate strategy for patients with AF The recommended drugs for rate control are beta-blockers (e.g. atenolol, metoprolol) or nondihydropyridine calcium channel blockers (verapamil, diltiazem). In patients with newly diagnosed AF for whom antithrombotic therapy is indicated, treatment should be initiated with minimal delay Warfarin is first choice anticoagulant. The newer oral anticoagulants (rivaroxaban and dabigatran) have a limited place in the local treatment pathway (see /AntrialFibrillationguidelineforNOACforprecentionofstrokeJuly2012versiontwo.pdf ) The GRASP-AF tool can be used to identify patients with a CHADS2 score of 2 or more who would benefit from a review to assess the issue of anticoagulation (see ) If CHADS2 <2 or uncertain then use CHA2DS2-VASC HASBLED is a useful tool for clinicians to assess bleeding risks Risk assessment tools are an aid to guide prescribing. JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 1 of 7 First produced: March Updated: September 2006/ March 2010/ August 2012

2 Management of atrial fibrillation Acute onset AF consider urgent admission if there is a clear history of onset on AF within the past 24 hours. Pharmacological cardioversion can often be achieved successfully without the need for lengthy delays awaiting anticoagulation Rate control with chronic anticoagulation is usually the best strategy for the majority of patients with AF. Rate control is usually as effective as rhythm control in relieving symptoms and reduces the need for hospitalization and rhythm-maintenance drugs. In patients with atrial flutter, cardioversion may be the preferred option. Attempts to restore sinus rhythm are appropriate if there are symptoms despite adequate rate control or inability to obtain adequate rate control. The recommended drugs for rate control are beta-blockers (e.g. atenolol, metoprolol) or nondihydropyridine calcium channel blockers (verapamil, diltiazem). Digoxin should only be used as a first line agent in a small minority of cases. It is useful in combination if poor rate control is achieved on one medication. Beta-blockers are the preferred rate-slowing drugs when they are clearly indicated for another reason e.g. LV systolic dysfunction; when hypertension is associated with AF and LVSD is normal, a non-dihydropyridine calcium channel blocker may be a better choice. Patients with AF should be advised to receive chronic anticoagulation with adjusted- dose warfarin (target INR 2-3), unless they are at moderate risk for stroke and have contraindications to the use of warfarin, in which case aspirin 75mg daily should be used. Treatment should be initiated with minimal delay after the appropriate management of comorbidities. Very low risk patients (CHA2DS2-VASC=0) do not require anticoagulation or aspirin. Reassess the risks and benefits of continued anticoagulation after 3 months if INR is consistently below 2 then the stroke risk is not being reduced and if INR is consistently above 3 the risk of a major bleed is increased consider aspirin or new oral anticoagulants in these patients if tighter INR control cannot be achieved. The CHADS 2 score is recommended for assessing the risk of stroke and CHA2DS2-VASC if score is 1 or uncertain. It is important to take into account patients attitudes to anticoagulation and their absolute risk of stroke, to aid decision-making in choosing warfarin or aspirin. Transthoracic echo should be considered for the majority of patients because they often have structural/functional heart disease, which may be difficult to ascertain clinically (e.g. left ventricular systolic dysfunction, pulmonary hypertension) and that may require specific management. For those patients who are appropriate to undergo cardioversion to achieve sinus rhythm, both direct current cardioversion and pharmacological conversion are appropriate options. Pharmacological cardioversion is most successful within 72 hours of AF onset Paroxysmal AF The anticoagulation guidelines for paroxysmal AF are the same as for patients with persistent and permanent AF. The first line therapy to maintain sinus rhythm is a beta-blocker. JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 2 of 7

3 Management of AF Suspected AF (Irregular pulse, palpitations syncope) ECG, FBC, TFT, U&Es Consider alternative diagnosis No Confirm AF? Yes Mitral valve stenosisrefer to consultant (commence anticoagulation) Consider underlying causes Hypertension Coronary artery disease Valve stenosis Chest infection/ COPD Thyrotoxicosis Cardiomyopathy Alcohol Commence anticoagulation/aspirin if appropriate Uncertain- consider referral to consultant Onset <24 hoursconsider admission for cardioversion Underlying causes exist Treat and review No identifiable cause Is AF still present? Yes Is referral for cardioversion indicated? Yes Refer to consultant No No Review regularly Manage with rate control and antithrombotic therapy Suitability for cardioversion/rhythm control strategy: Symptoms despite adequate rate control Younger patients e.g. age <65 years Recent onset and reversible precipitant e.g. chest infection, recent cardiac surgery Atrial flutter Some patients with heart failure Presenting for first time with lone AF Refer patients For cardioversion Acute AF <24 hours Who need a full cardiological assessment e.g.murmur,?ihd Who respond poorly to therapy Paroxysmal AF still symptomatic despite beta-blocker Unable to achieve adequate rate control e.g. >100 at rest or >80 JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 3 of 7

4 Treatment strategy decision tree Confirmed diagnosis of AF Further investigations and clinical assessment including risk stratification for stroke/thromboembolism Paroxysmal AF Persistent AF Permanent AF Rhythm or Rate? Rhythm-control Remains symptomatic Failure of rhythm-control Rate-control Try rhythm-control first for patients with persistent AF who are symptomatic who are younger presenting for the first time with lone AF secondary to a treated or corrected precipitant with congestive heart failure Try rate-control first for patients with persistent AF: Over 65 with coronary artery disease with contraindications to antiarrhythmic drugs unsuitable for cardioversion 1 Without congestive heart failure 1 Patients 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 antiarrhythmic drugs or nonpharmacological approaches; an ongoing but reversible cause of AF (e.g. thyrotoxicosis). JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 4 of 7

5 Assessing the risk of stroke in AF Assessing stroke risk in AF patients ASSESS CHADS2 SCORE FIRST CHADS 2 CHADS 2 Stroke Risk % pa CHF = Hypertension = Risk category High CHADS 2 or CHA 2 DS 2 - VASc 2 Recommended Stroke Prevention Therapy Oral anticoagulation (OAC) Age 75 = Diabetes = Stroke/TIA = Moderate particularly age > 65 & evidence of vascular disease 1 Either OAC or aspirin mg daily Preferred: OAC rather than aspirin IF CHADS 2 = 0 or 1 or uncertain of risk USE CHA2DS-VASC CHA 2 DS 2 -VASc items CHF of LVEF<40% = 1 Hypertension = 1 Age 75= 2 CHA 2 DS 2 -VASc Stroke Risk % pa No risk factors and age < 65 0 Either no antithrombotic therapy or aspirin Preferred: no antithrombotic therapy Diabetes = Stroke/TIA = Vascular Disease = Age = Female = Warfarin should be considered first line for all patients including the elderly unless absolutely contraindicated. Contraindications include recent life threatening haemorrhage, pregnancy and known hypersensitivity to warfarin. (See BNF for complete list). JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 5 of 7

6 *The use of the newer oral anticoagulants (dabigatran and rivaroxaban) is limited and covered in a separate guidance. There use is limited in patients with A CHADS2 score of 2 AND meet NICE criteria plus one of the following: o Poor control with Warfarin after a 6 month trial (provided compliance is good): o TTR < 50%; o More than 2 INRs >8.0 or more than 3 INR s > 5 in a given 6 month period. Or Cannot tolerate warfarin, acenocoumarol and phenindione. See trialfibrillationguidelinefornoacforprecentionofstrokejuly2012versiontwo.pdf NNTs from the CHADS 2 These may aid discussion with the patient when deciding the benefits of warfarin over aspirin CHADS2 Adjusted annual stroke rate 20% RRR with aspirin NNT to prevent one stroke for aspirin compared to no treatment 60% RRR with warfarin NNT to prevent one stroke for warfarin compared to no treatment 0 1.9% 1.5% % % 2.24% % % 3.2% % % 4.7% % % 6.8% % % 10.0% % % 14.56% % 9 It is reasonable to assume that the risk of bleeding from drug therapy is independent of the CHADS 2 score. If warfarin is used instead of aspirin, for every 1,000 people treated for a year, there will be nine more major bleeds 1. This gives a NNH of 111. Hence, one can estimate the risk/benefit ratio for using warfarin instead of aspirin for each CHADS 2 score. 1. JAMA 2002; 288: Both the antithrombotic benefits and the potential bleeding risks of long-term anticoagulation should be explained to and discussed with the patient. The assessment of bleeding risk should be part of the clinical assessment of patients before starting anticoagulation therapy. FALLS ARE NOT A MAJOR RISK FACTOR FOR BLEEDING IN ANTICOAGULATED PATIENTS (M Man-Son-Hing et al, Arch Intern Med 1999; 159: ) JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 6 of 7

7 Assess bleeding risk using the HAS- BLED tool. HAS-BLED bleeding risk score has been developed to help guide choice of therapy. A score 3 indicates high-risk and hence action and regular review of these patients is required (this may include a referral to a haematology consultant led clinic) HAS- BLED Major Bleeding Risk Letter Clinical Characteristic* Points HAS-BLED score (total points) Major Bleed Risk % pa H Hypertension A Abnormal renal & liver function 1 or S Stroke B Bleeding diathesis L Labile INR E Elderly 1 5 to 9 Insufficient data D Drugs/ alcohol 1 or 2 *HAS-BLED Notes Hypertension: systolic blood pressure >160 mm Hg. Renal function: creatinine >200 or dialysis. Liver function: chronic liver disease (eg, cirrhosis) or bilirubin >2x ULN +AST /AlkP >3x upper limit normal). Bleeding: previous bleeding, bleeding diathesis or unexplained anaemia. Labile INRs: Time in Treatment Range <60%. Drugs: concomitant use of drugs, e.g. antiplatelet agents and non-steroidal antiinflammatory drugs. Alcohol: excess alcohol HAS-BLED score N Bleeds, n Bleeds/100 patients* Any score *p for trend of increasing bleeding risk with increasing score (Adapted from 1 st validation of HAS-BLED in a European AF population) JAPC Derbyshire Guideline - Management of Atrial Fibrillation Page 7 of 7

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