Atrial Fibrillation - management AF in primary care

Care map information Information resources for patients and carers Updates to this care map Hauora Maori Pacific Clinical presentation AF <48 hours Clinical assessment Assess stroke risk Consider bleeding risk Antithrombotic therapy Referral for echocardiography Consider referral to Cardiology Management in primary care Consider treatment options Rate control treatment Monitor progress Uncontrolled Atrial Fibrillation (AF) Review treatment options Refer to Hospital Cardiology Consider referral to Cardiologist Page 1 of 10

1 Care map information The scope of this Pathway This Pathway should be used only for patients in which it will influence the patient management. It is to be used as a guide and doesn't replace clinical judgement. 2 Information resources for patients and carers Patient-centred resources: overview of atrial fibrillation information for patients, family and friends (leaflet) causes and symptoms Medications Patient information about Warfarin. Printable leaflets are available in the following languages: English language leaflet Samoan language leaflet Tongan language leaflet Chinese language leaflet Korean language leaflet Nuiean language leaflet Patient information about Dabigatran Rate/rhythm control medications: beta blockers calcium channel blockers Digoxin Amiodarone Flecainide Language translation assistance: HBDHB Interpreting Service - phone 06 878 8109 ext 5805 or email interpreting@hawkesbaydhb.govt.nz to make an appointment (charges may apply) These websites may help with simple words and phrases: Babelfish Google translate Language Line - professional interpreters are available, free of charge, for telephone-based sessions (44 languages are supported). Phone 0800 656 656 Monday - Friday 9am - 6pm Saturday 9am - 2pm Bookings are not usually necessary. For longer consultations (for example, a nurse consultation for a newly diagnosed patient) it is best to make a booking at least 24 hours in advance by calling the above number or emailing language.line@dia.govt.nz and providing your contact details and a summary of the service you require (time and date of the meeting, language, approximate length of the appointment, gender of interpreter (if relevant). 3 Updates to this care map Page 2 of 10

Date of publication: xxx Date of review and republication: XXX This care map has been developed in line with consideration to evidenced based guidelines. For further information on contributors and references please see the Pathway's Provenance Certificate 4 Hauora Maori Maori are a diverse people and whilst there is no single Maori identity, it is vital practitioners offer culturally appropriate care when working with Maori whanau. It is important for practitioners to have a baseline understanding of the issues surrounding Maori health. This knowledge can be actualised by (not in any order of priority): clinicians acknowledging Te Whare Tapa Wha (Maori model of health) when working with Maori whanau asking Maori clients if they would like their whanau or significant others to be involved in assessment and treatment asking Maori clients about any particular cultural beliefs they or their whanau have that might impact on assessment and treatment of the particular health issues consider the importance of introductions and mihimihi ( whanaungatanga ) - a process that enables the exchange of information to support interaction and meaningful connections. This means taking a little time to ask where this person is from or where they have significant connections to. This information is reciprocated; i.e. the health professional also shares where they are from knowledge of the Hawke s Bay health sector s strategies and initiatives for improving Maori health and wellbeing having a historical overview of legislation that has impacted on Maori well-being Training is available through the Hawke s Bay DHB to assist you to better understand Maori culture and to better engage with Maori patients. Contact the coordinator (education@hbdhb.govt.nz) to request details of the next courses. For more information on the regional and national Maori Health Strategies go to: Mai Maori Health Strategy 2014-2019- Full file or Summary diagram He Korowai Oranga: Maori Health Strategy - sets the Government s overarching framework to achieving the best health outcomes for Maori. Hawke s Bay District Health Board contracts Maori Providers to deliver breast and cervical screening, and mobile nursing teams. A referral to one of these providers may assist Maori patients to feel more comfortable about receiving these services. Central Hawke s Bay: Central Health - http://www.centralhealth.co.nz/ Hastings: Te Taiwhenua o Heretaunga - http://www.ttoh.iwi.nz/ Kahungunu Health Services (Choices) - http://www.choices.maori.nz/ Napier: Te Kupenga Hauora - http://www.tkh.org.nz/ Wairoa: Kahungunu Executive - http://www.familyservices.govt.nz/directory/viewprovider.htm? id=5352&back=searchprovideralphabetical.htm?letter=k&providerid 5 Pacific Pacific people value their culture, language, families, education and their health and wellbeing. Many Pacific families have a religious affiliation to a local church group. The Pacific people are a diverse and dynamic population: more than 22 nations represented in New Zealand each with their own unique culture, language, history, and health status share many similarities which we have shared with you here in order to help you work with Pacific patients more effectively for many families language, cost and access to care are barriers Page 3 of 10

Pacific ethnic groups in Hawke's Bay include Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau, Kiribati and Tuvalu. Samoan and Cook Island groups are the largest and make up two thirds of the total Pacific population. There is a growing trend of inter-ethnic relationships and New Zealand born Pacific populations. Acknowledge The FonoFale Model (Pacific model of health) when working with Pacific peoples and families. General guidelines when working with Pacific peoples and families (information developed by Central PHO, Manawatu): Cultural protocols and greetings Building relationships with your Pacific patients Involving family support and religion during assessments and in the hospital Home visits Hawke s Bay-based resources HBDHB interpreting service 06 8788 109 ext 5805 (no charge for hospital patients; charges apply for community-based translations) Tim Hutchins- Pacific Navigation Services LTD 027 9719199 Services to assist Pacific peoples to access healthcare (SIA) Improving the Health of Pacific People in Hawke s Bay Pacific Health Action Plan Ministry of Health resources: Ala Mo'ui - Pathways to Pacific Health and Wellbeing 2014-2018 Primary care for Pacific people: a Pacific and health systems approach Health education resources in Pacific languages (links to a webpage where you can download resources) 6 Clinical presentation Definitions: Persistent Atrial Fibrillation (AF) is characterised by episodes of AF that last more than seven days and that has not spontaneously resolved within this time Permanent AF is characterised by AF that has been present for more than one year and cardioversion has failed or not been attempted Paroxysmal Atrial Fibrillation (AF): is characterised by recurrent episodes of AF that last less than seven days (although often less than 24 hours) and resolve spontaneously within that time 7 AF <48 hours If duration is < 48hrs, then pharmacological or synchronised electrical cardioversion may be considered in secondary care. Although most patients in Atrial Fibrillation (AF) present without haemodynamic compromise, some are significantly compromised and require immediate hospitalisation and urgent intervention to: alleviate symptoms of breathlessness, chest pain, and loss of consciousness restore haemodynamic stability Patients at the greatest risk from haemodynamic instability are those with: a ventricular rate greater than 150bpm ongoing chest pain critical perfusion Refer to Emergency Department for urgent assessment if the person has any of the following: a rapid pulse (greater than 150 bpm) and/or low blood pressure (systolic blood pressure less than 90mmHg) loss of consciousness, severe dizziness, ongoing chest pain, or increasing breathlessness a complication of AF, such as stroke, TIA or acute heart failure 8 Clinical assessment Page 4 of 10

When reviewing established Atrial Fibrillation (AF) [3]: check for ongoing symptoms, both at rest and upon exercise assess heart rate (apex rate by auscultation or ECG and radial pulse rate) check for complications of AF (eg Heart failure) and assess BP a baseline ECG chest xray thyroid function test 9 Assess stroke risk Stroke risk [3]: Atrial Fibrillation (AF) is an independent risk factor for stroke the annual risk for stroke is 5-6 times higher in people with AF than in people in sinus rhythm Stroke that occurs in association with AF is also more likely to result in greater mortality, morbidity, disability, and longer hospital stays than stroke in people without AF Risk should be reassessed [3]: if patient develops diabetes, hypertension or cardiovascular disease when patient reaches age 65 and 75 years The European Society of Cardiology (ESC) recommends using the CHA 2 DS 2 VASc score for a more detailed and comprehensive stroke risk assessment [2] see CHADS VASc Score 10 Consider bleeding risk The European Society of Cardiology (ESC) recommends using the HAS-BLED bleeding risk score [2], see HAS-BLED Bleeding Risk Score 11 Antithrombotic therapy Antithrombotic therapy is recommended for all patients with Atrial Fibrillation (AF) unless either [2]: patient is at low risk (eg lone AF, age less than 65 years); or contraindications are present (eg inability to cope with anticoagulation monitoring) The absolute benefit of antithrombotic therapy, eg warfarin or dabigatran for stroke prevention increases with age [2]. AF patients age 75 years and older (even with no other associated risk factors) have a significant stroke risk and derive benefit from warfarin or dabigatran over aspirin [2]. See antithrombotic therapy recommendations based on the CHA 2 DS 2 VASc scoring system. Cultural considerations: There are numerous accounts of the anti-platelet effects of kawakawa. Clinicians need to ensure they have asked Maori clients if they are using any Rongoa Maori (Rongoa Maori encompasses herbal remedies, physical therapies and spiritual healing). Management Options for Primary Care Initiated Anticoagulation Novel oral anticoagulants offer the benefit of fixed dosing regimes with no requirement for blood testing or the need for care with diet. The following need to be considered: dose adjustment in people with creatinine clearance of less than 50 ml/min contraindicated in creatinine clearance of less than 30 ml/min Patient information about Dabigatran Warfarin therapy: Page 5 of 10

General practice may choose to manage the initiation of warfarin therapy and ongoing dosing management. Once a patient is stable on anticoagulation medication, on-going INR monitoring may be conducted at selected community pharmacies. Please contact the selected pharmacy to arrange ongoing INR monitoring. Patients should be contacted by the GP practice or testing pharmacy after each INR test to provide: their result the date of their next INR their warfarin dose See guide for initiation of low dose warfarin therapy add link Patient information about Warfarin. Printable leaflets are available in the following languages: English language leaflet Samoan language leaflet Tongan language leaflet Chinese language leaflet Korean language leaflet Nuiean language leaflet Marevan and Coumarin are available in NZ Marevan accounts for approximately 95% of prescriptions of warfarin in NZ the brands are not interchangeable and come in different tablet strengths during community initiation only 1mg tablets should be used to minimise confusion attach the following note to patients first prescription requesting pharmacist counselling and information on oral anticoagulant use Anticoagulant Prescription Attachment NB: Stroke risk factors have a cumulative effect on overall stroke risk. For example, if the patient is in the moderate stroke risk category but has more than one risk factor for stroke, e.g. hypertension and diabetes, there may be a stronger case for choosing warfarin over aspirin [1]: if warfarin or dabigatran is offered, aspirin should not usually be taken concomitantly, as it provides no additional benefit and may increase the risk of bleeding [1] if stroke risk is uncertain, start aspirin whilst awaiting cardiology assessment [1] for patients with AF who have mechanical heart valves, it is recommended that the target intensity of anticoagulation should be based on the type and position of the prosthesis, maintaining an INR of at least 2.5 in the mitral position and at least 2.0 for an aortic valve [2] the selection of antithrombotic therapy should be considered using the same criteria irrespective of the pattern of AF (ie paroxysmal, persistent or permanent [2] NB: The use of clopidogrel or a combination of aspirin and clopidogrel are not recommended for managing AF in primary care [3]. 12 Referral for echocardiography Strongly recommended transthoracic echocardiography (TTE) if [1]: there is a risk or suspicion of underlying heart disease, eg signs of heart failure or cardiac murmur [3] information on cardiac structure or function is needed to make a decision about starting antithrombotic treatment TTE may help to clarify risk of stroke in some patients, eg those with suspected left ventricular dysfunction without overt heart failure [3] 13 Consider referral to Cardiology Consider a referral to the Cardiologist: Page 6 of 10

patients in whom rhythm control including cardioversion is considered patients whose rate control is poor patients whose symptoms cannot be controlled patients with abnormal ECG or echocardiogram patients who have contraindication or intolerance of standard rate control therapies Direct referral to Echocardiography: patients with new AF where a scan would influence management 14 Management in primary care Both rhythm control and rate control are acceptable strategies in the management of Atrial Fibrillation (AF). Rate control is needed for many patients with AF unless the heart rate during AF is naturally slow. Rhythm control may be considered in preference to rate control, if: the patient is symptomatic despite adequate rate control; or a rhythm control strategy is selected due to: the degree of symptoms younger age higher activity levels Permanent AF is managed by rate control. The initial therapy after onset of AF should always include adequate antithrombotic treatment and control of the ventricular rate. Rate control can be started in primary care, but rhythm control should only be started following specialist assessment. Refer to cardiologist for rhythm control treatment if patient: is symptomatic is aged 65 years or younger presents for the first time with lone AF, indicated by: no history of cardiovascular disease or hypertension no abnormal cardiac signs on physical examination a normal chest x-ray and, apart from the presence of AF, a normal ECG ie no indication of prior myocardial infarction or left ventricular hypertrophy presents with AF secondary to a treated or corrected precipitant, e.g. infection Rate control may be the preferable initial strategy in patients [1]: with permanent AF over age 65 years with coronary heart disease who have contraindications to antiarrhythmic drugs with contraindications to cardioversion, such as: AF of more than 12 months duration several previous failed attempts at cardioversion structural disease precluding long-term maintanence of sinus rhythm, eg mitral stenosis with contraindications to anticoagulation If there is uncertainty about which option is best, seek specialist advice. Also refer to a cardiologist (for either rhythm or rate control) if: rate control medication that can be administered in primary care is contraindicated patient has been prescribed rhythm control treatment in secondary care and presents with persistent or recurring symptoms 15 Consider treatment options Page 7 of 10

Consider rate control treatment if either of the following apply [3]: resting heart rate is persistently 100 beats per minute or more heart rate is fast on exertion, resulting in limited exercise tolerance 16 Rate control treatment The ventricular rate may be controlled using: beta blockers rate limiting calcium channel blockers (verapamil or diltiazem) or digoxin (third line treatment) The choice of a medicine for rate control in primary care should be guided by the presence of co-morbidities and also by the level of activity of the patient. See Rate Control Medication As a guide, target heart rate should be 100 beats per minute at rest and 115 beats per minute with moderate walking. Seek Cardiologist advice if there is uncertainty over whether to prescribe medication and/or if patients continue to experience symptoms related to Atrial Fibrillation (AF) during activity [3]. 17 Monitor progress Follow-up within 1 week [3]. Check whether the patient is tolerating the medication if the patient is unable to tolerate the current medication, prescribe an alternative. Review symptoms, heart rate, and blood pressure. 18 Uncontrolled Atrial Fibrillation (AF) As a guide, target heart rate should be 100 beats per minute at rest and 120 beats per minute with moderate walking. Seek Cardiologist advice if there is uncertainty over whether to prescribe medication and/or if patients continue to experience symptoms related to Atrial Fibrillation (AF) during activity [3]. 19 Review treatment options If the patient's symptoms and/or heart rate are not controlled, consider increasing the dose to control symptoms. If the patient is taking the maximum drug dose, consider combining drug treatments. See recommended rate control medications Rate Control Medication 21 Consider referral to Cardiologist Refer to a Cardiologist if symptoms are not controlled with, or patient does not tolerate, a beta-blocker plus digoxin, or a calcium channel blocker plus digoxin [3] A Cardiologist may consider/recommend the use of [1]: amiodarone diltiazem with a beta-blocker Page 8 of 10

Alternatively, a Cardiologist may consider a non-pharmacological approach, such as atrioventricular node ablation coupled with pacing [3]. Page 9 of 10

Key Dates Published:, by Valid until: Evidence summary for Atrial Fibrillation - management AF in primary care Page 10 of 10