Can the NICE guidelines on the management of atrial fibrillation improve its management?

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Can the NICE guidelines on the management of atrial fibrillation improve its management? Powered By Docstoc
					■ EDITORIALS                                                                              Clinical Medicine 2009, Vol 9, No 3: 207–9

Can the NICE guidelines on the management of atrial fibrillation
improve its management?

Chee W Khoo and Gregory YH Lip

Atrial fibrillation (AF) is the most common sustained cardiac        lication of the NICE guidelines.8 Their study suggests that only
arrhythmia seen in clinical practice. The incidence of AF            84% of 131 patients with diagnosis of AF had either electrocar-
increases significantly with advancing age, with the prevalence      diogram (ECG) documentation in primary and/or secondary
being 8% for population of age 80 and above.1 For those who are      care. Almost half of the patients with AF were managed in pri-
40 years and older, the lifetime risk for the development of AF is   mary care alone and the diagnosis of AF was generally accurate.
1 in 4 in both men and women.2,3 With an ageing population, an       The use of echocardiography is an important part of manage-
increase in the incidence and prevalence of AF has been reported     ment, and in the paper by Loo et al only 44% of the study popu-
worldwide.4,5 Indeed, AF has become such a common problem            lation underwent an echocardiogram.8 However, this percentage
that it is now described as ‘a major epidemic’.                      increases in those who were diagnosed with AF after 2000 and
   Due to the close relationship between AF, stroke and throm-       those who had cardiology input from secondary care. This could
boembolism there has been a need for increased caution.              probably be explained by a better understanding of the manage-
Irrespective of applying a rate-control or rhythm-control            ment of AF, better educational efforts and, perhaps, a better pro-
strategy thromboprophylaxis remains the essential core of any        vision of echocardiography services from secondary care.
AF management strategy. Given that AF is so common various              The overall rate of anticoagulation was higher than other
management guidelines have been published over the last few          studies, but there remains a discrepancy, with only about half of
years.6,7 In the UK, the evidence-based national guidelines for
the management of AF were published by the National Institute
for Health and Clinical Excellence (NICE) in June 2006.7 The          Box 1. Priorities for implementation in the National Institute
methodology for the NICE guidelines differs from other expert         for Health and Clinical excellence guidelines for the man-
consensus-based guidelines in that, following agreement and           agement of atrial fibrillation (AF).
definition of a scope for the NICE guideline, pertinent questions
                                                                      The following five recommendations have been identified as priorities
on AF management are formulated and a formal systematic               for implementation:
review undertaken by an information scientist who would               1. An electrocardiogram should be performed in all patients,
retrieve, assess and organise sources of published evidence. The         whether symptomatic or not, in whom AF is suspected because
latter is then critically appraised and graded by a health service       an irregular pulse has been detected.
research fellow and, if needed, a health economist. The synthe-       2. As some patients with persistent AF will satisfy criteria for
sised evidence is reviewed and debated by a guideline develop-           either an initial rate control or rhythm control strategy:
ment group (GDG), which included multidisciplinary represen-             • the indications for each option should not be regarded as
                                                                           mutually exclusive and the potential advantages and
tatives from various learned bodies and specialist organisations.
                                                                           disadvantages of each strategy should be explained to
   Despite the published guidelines for the management of AF,              patients before agreeing which to adopt
this common arrhythmia remains poorly managed, both in pri-              • any comorbidities that might indicate one approach rather
mary and secondary care, with marked variation in the                      than the other should be taken into account
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