ACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY

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1 Care Pathway Triage category ATRIAL FIBRILLATION PATHWAY ACCIDENT AND EMERGENCY DEPARTMENT/CARDIOLOGY AF/ FLUTTER IS PRIMARY REASON FOR PRESENTATION YES NO ONSET SYMPTOMS OF AF./../ TIME DURATION OF AF HOURS SELF PRESENTATION AMBULANCE AMBULANCE SHEET E/U NO. BP..../... HEART RATE..TEMP. O 2 SATS % RESP RATE BM SIGNED TIME..:.. DATE. TREATMENT- ANALGESIA IV CANNULA CHEST X-RAY REQUESTED BLOODS - U&E, GLUCOSE, CHOLESTEROL, FBC, INR (IF ON WARFARIN), TFTs, TROPONIN-T ECHO- IF PLAN FOR RHYTHM CONTROL, SUSPECTED STRUCTURAL HEART DISEASE, OR FOR EMBOLIC RISK STRATIFICATION DATE MEDICATION & DOSE (STAT) ROUTE PRESCRIBER S SIGNATURE STAT DOSE FOR USE IN AE ONLY ASPIRIN 300mg ORAL ATENOLOL 25mg ORAL AMIODARONE 600mg ORAL DIGOXIN 500 micrograms ORAL TIME GIVEN BY Page 1 of 8

2 ACCIDENT & EMERGENCY ASSESSMENT Seen By Time. :.. HISTORY OF PRESENTING COMPLAINT - Time of Onset.. :.. Hrs. PAST MEDICAL HISTORY AND RISK FACTORS ISCHAEMIC HEART DISEASE MYOCARDIAL INFARCTION CABG HEART FAILURE DIABETES MELLITUS TYPE I TYPE II HYPERTENSION HYPERLIPIDAEMIA PRIOR CVA/TIA PERIPHERAL ARTERIAL DISEASE RENAL IMPAIRMENT MITRAL VALVE DISEASE ALCOHOL EXCESS HYPERTHYROIDISM CURRENT MEDICATIONS ALLERGIES -. Page 2 of 8

3 SOCIAL HISTORY ALCOHOL - Y / N,. HOW MANY UNITS PER WEEK.,IF MORE THAN 8 UNITS FOR MALES. 6 UNITS DAILY FOR FEMALES.(DOH GUIDELINES) REFER TO WUTH ALCOHOL CARE PATHWAY. FAMILY HISTORY Examination BP.../... HR... O 2 SATS... RESP RATE.TEMP. Page 3 of 8

4 EXAMINATION CONTINUED. CLINICAL IMPRESSION INVESTIGATIONS ARRANGED (TICK IF REQUESTED) ECG CHEST XRAY BLOODS U&E, FBC, TFT S, GLUCOSE, CLOTTING COMPLETE CHADS2 SCORE (SEE PAGE 7) FOR ALL PATIENTS. SCORE = MANAGEMENT PLAN REFERRED -..SIGNED BLEEP..TIME REFERRED..:.. Page 4 of 8

5 TRANSFER TO CCU START TREATMENT DOSE OF LOW MOLECULAR WEIGHT HEPARIN (UNLESS ON WARFARIN WITH INR> 2) TINZAPARIN SC 175UNITS/kg DAILY OR MANAGEMENT OPTIONS FIT FOR DISCHARGE FROM EMERGENCY DEPARTMENT: ASPIRIN 75mg ONCE DAILY; CONSIDER REFERAL TO AF CLINIC; (FAX REFERAL FORM TO EXT 8070) AF < 48 HOURS: TRANSFER TO CCU FOR ACUTE CARDIOVERSION (SEE NICE GUIDANCE ON PAGE 6 OF PATHWAY) AF >48 HOURS: CONSIDER TRANSFER TO HAC FOR POSSIBLE ELECTIVE DC CARDIOVERSION (SEE NICE GUIDANCE ON PAGE 6 OF PATHWAY) AF + SIGNIFICANT CO-MORBIDITY; TRANSFER TO MAU; CONSIDER REFERAL TO CARDIOLOGIST ATRIAL FLUTTER; REFER TO CARDIOLOGIST AF < 48 HOURS OR ON WARFARIN (INR >2) RHYTHM CONTROL IF ALSO TREATING AS ACUTE CORONARY SYNDROME START ENOXAPARIN SC 1mg/kg TWICE DAILY IF RENAL IMPAIRMENT, PLEASE REFER TO THE PRESCRIBING GUIDE ON THE CHOICE OF LOW MOLECULAR WEIGHT HEPARIN. Yes No ATTEMPT MEDICAL CARDIOVERSION (IF HAEMODYNAMICALLY STABLE); IV FLECAINIDE INFUSION 2mg/kg (MAX 150mg) NOT IF IHD OR LV IMPAIRMENT OR ORAL AMIODARONE 600mg TDS (HIGH DOSE REGIME ONLY IF HEART RATE > 80BPM) 2 DAYS IF MEDICAL CARDIOVERSION UNSUCCESSFUL CONSIDER DC CARDIOVERSION FAST FOR 6 HOURS REFER TO CARDIOLOGY TEAM TO ARRANGE IF CARDIOVERSION UNSUCCESSFUL, USE RATE CONTROL MANAGEMENT FOR MAXIMUM AF > 48 HOURS (OR ON WARFARIN WITH INR < 2) DECIDE ON RATE OR RHYTHM CONTROL MANAGEMENT SEE NICE GUIDELINES ON PAGE 6 OF PATHWAY PERFORM EMBOLIC RISK SCORE (SEE PAGE 7). (DISCUSS WITH PATIENT) ELECTIVE DC CARDIOVERSION - WILL NEED: o WARFARIN FOR 3 WEEKS BEFORE AND 4 WEEKS AFTER CARDIOVERSION AND o AMIODARONE (STANDARD LOADING) FOR 3 WEEKS BEFORE AND UNSPECIFIED PERIOD AFTER CARDIOVERSION o ARRANGE CARDIOLOGY FOLLOW UP Page 5 of 8

6 RHYTHM CONTROL OR RATE CONTROL (NICE GUIDANCE 2006) RATE CONTROL RATE CONTROL FAVOURED BY; > 65 YEARS IHD CONTRAINDICATIONS TO ANTIARRHYTHMIC DRUGS UNSUITABLE FOR CARDIOVERSION, PRIOR FAILED CARDIOVERSION. DRUGS FOR RATE CONTROL: 1 ST LINE: ATENOLOL 25MG ORAL STAT THEN DAILY 2 ND LINE: TILDIEM LA 200MG (DILTIAZEM) ORAL STAT THEN DAILY 3 RD LINE: DIGOXIN 500MICROGRAMS ORAL STAT (125 MICROGRAMS DAILY); ESPECIALLY >75 YEARS OR HEART FAILURE RHYTHM CONTROL RHYTHM CONTROL FAVOURED BY < 65 YEARS SYMPTOMATIC 1 ST PRESENTATION OF ATRIAL FIBRILLATION AF SECONDARY TO A TREATED PRECIPTATING FACTOR CCF PROPHYLACTIC TREATMENT IN PAF REFER TO CARDIOLOGIST ANTI ARRHYTHMIC DRUG PROPHYLAXIS DEPENDS ON SEVERITY OF AF SYMPTOMS AND RISK OF PRO-ARRHYTHMIAS (POTENTIAL TO PRODUCE DANGEROUS ARRHYTHMIAS) 1. INFREQUENT WELL TOLERATED AF NO DRUG TREATMENT 2. RECURRENT SYMPTOMATIC AF ATENOLOL OR DILTIAZEM / VERAPAMIL 3. RECURRENT SYMPTOMATIC AF DESPITE RATE SLOWING DRUGS ADD OR SUBSTITUTE ANTIARRHYTHMIC DRUGS (SEE BELOW) 4. RECURRENT SYMPTOMATIC AF DESPITE RATE SLOWING DRUGS AND ANTIARRHYTHMIC DRUGS CONSIDER REFERRAL FOR RADIOFREQUENCY ABLATION PROPHYLACTIC DRUGS (SEE BELOW - SEEK ADVICE OF CARDIOLOGIST) FLECAINIDE: DO NOT USE IN IHD OR STRUCTURAL HEART DISEASE OR ATRIAL FLUTTER. CAN CAUSE VT, VF OR DEATH. AMIODARONE: CHECK TFTS, LFTS AND VITALOGRAM BASELINE AND YEARLY. WARN ABOUT SIDE EFFECTS E.G. PHOTOSENSITIVITY, PULMONARY INFILTRATION. ALWAYS FOLLOW UP IN SPECIALIST CLINIC OR USE PREDEFINED TREATMENT COURSE LENGTHS E.G. 3 OR 6 MONTHS MANAGEMENT PLAN DISCUSSED WITH PATIENT.. (SIGNED) Page 6 of 8

7 ANTI-EMBOLIC RISK SCORE (CHADS2) Yes No CONGESTIVE HEART FAILURE 1 0 HYPERTENSION (SYSTOLIC >160MMHG) 1 0 AGE > 75 YEARS 1 0 DIABETES 1 0 PRIOR STROKE OR TIA 2 0 TOTAL SCORE RISK SCORE HIGH RISK CHADS2 SCORE 2-6 MEDIUM-RISK CHADS2 SCORE 1 LOW-RISK CHADS2 SCORE 0 MANAGEMENT 4.0% % ANNUAL RISK PREVIOUS ISCHAEMIC STROKE, TIA OR THROMBOEMBOLIC EVENT. > 75 YEARS AND HYPERTENSIVE, DIABETES OR VASCULAR DISEASE CLINICAL EVIDENCE OF VALVE DISEASE OR HEART FAILURE OR IMPAIRED LV FUNCTION 2.8%ANNUAL RISK > 65 YEARS WITH NO HIGH RISK FACTORS < 75 YEARS WITH HYPERTENSION, DIABETES OR VASCULAR DISEASE. TREATMENT WARFARIN WARFARIN OR ASPIRIN 1.9% ANNUAL RISK < 65 YEARS WITH NO HIGH OR LOW RISK FACTORS ASPIRIN 75MG 300MG DAILY REFERENCE ; BF GAGE ET AL. VALIDATION OF CLINICAL CLASSIFICATION SCHEMES FOR PREDICTING STROKE RESULTS FROM THE NATIONAL REGISTRY OF ATRIAL FIBRILLATION. JAMA : IF YOU INITATE TREATMENT WITH WARFARIN YES NO ASSESS RISK & BENEFIT (I.E. FALLS, ALCOHOL, COMPLIANCE) ARRANGE ORAL ANTICOAGULATION PACK AND COUNSELLING ARRANGE FOLLOW-UP INR APPOINTMENT PRESCRIBE WARFARIN ON ANTICOAGULANT CHART Page 7 of 8

8 EXAMINATION REVIEW. Page 8 of 8

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