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					          New Atrial Fibrillation/Flutter
           Pathway and GRASP Tool

         Kay Elliott
 British Heart Foundation
Arrhythmia Nurse Specialist

Dorset County Hospital NHS
     Foundation Trust
                                                        Aim

To Discuss:
• Primary/Secondary Care Pathway for
   new onset atrial fibrillation/Flutter
• GRASP* Tool – Identifying and risk
   stratifying chronic AF/Flutter in primary
   care
*Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation in Patients in Primary Care
                                      New Onset Atrial Fibrillation or Flutter
                                         Is the patient acutely unwell?
                          Yes                                                     No

                                                                              Primary Care
                     Admit to Hospital                 START WARFARIN AND RATE CONTROL (see box A)
                                                      Issue patient education leaflet:
                                                      ‘Atrial Fibrillation and Warfarin’. Attached, also
                                                      available: www.patient.co.uk/showdoc/23068883

                                                                  NEED FURTHER ADVICE?
          Box A: Rate control                                     CONTACT:
   First Line:                                                    BHF ARRHTYHMIA NURSE:
1.    1. Beta-blocker (e.g. Bisoprolol)                           01305 254920
   or a rate limiting calcium
   antagonist (e.g. Diltiazem), if beta-
   blocker contraindicated                                                           Persistent
2.    2. Digoxin – additional to optimise                         Fax referral to Rapid Access Atrial
   rate control, where required. As             Paroxysmal
                                                                  Fibrillation/Flutter
   monotherapy only in predominantly        Refer to cardiology
                                                                  Clinic.
   sedentary patients.                      team in the usual
                                                                  (Form attached. Also available on Dorset
                             NICE (2006)    way.
                                                                  County Hospital intranet or by contacting
                                                                  BHF Arrhythmia Nurse)



                                                                                    Rapid Access Atrial
                                            Cardiologist                         Fibrillation/Flutter Clinic
                                                      Rapid Access
                                             Atrial Fibrillation/Flutter Clinic
                                                ONE STOP APPOINTMENT
                                              (WITHIN 4 WEEKS OF REFERRAL)

               Cardiologist
               input into RAAF      1.    ECHO AND ECG
               clinic. Also         2.    BHF ARRHYTHMIA NURSE CLINIC:
               patients referred         q    Review history, symptoms, test and
Cardiologist   for DC                         examination results
               Cardioversion             q    Patient education
               from cardiology           q    Agree treatment plan: DC Cardioversion or
               clinic or in-                  Rate Control
               patient stay.             q    Arrange ongoing follow-up, where required




                 BHF Arrhythmia Nurse Specialist:                  Primary Care
                 Arrange DC Cardioversion                          Manage long-term
                                                                   warfarin and rate-
                                                                   control
                 Prepare for DC Cardioversion:
                 Weekly INR (Target 2.5-3.0), must have
                 INR >2.0 for four full weeks prior to DC
                 Cardioversion (see next page)




    DC Cardioversion – BHF ARRHYTHMIA NURSE/DAY SURGERY UNIT

q      Procedure
q      Review of medications and treatment pre-discharge
       (Cardiology Specialist Registrar and BHF Arrhythmia Nurse)
q      Review with BHF Arrhythmia Nurse at 4 weeks, ongoing treatment plan

N.B. Maintaining a therapeutic INR during the four weeks post successful
DC Cardioversion is important in terms of stroke risk reduction.
                        4 Weeks post procedure Follow-Up (NICE, 2006)
                                    BHF Arrhythmia Nurse
                               Is the Patient in Sinus Rhythm?



                            Yes/No
                                            YES              NO
       Cardiology Review
                                                       Depending on clinical indications
Patient remains symptomatic                            and patient preference either:
despite adequate rhythm or rate
control.                                               1.   Re-attempt DC Cardioversion with
                                                            amiodarone cover
Other cardiac complications are                        2.   Refer for ablation therapy
revealed.                                              3.   Rate control/Warfarin (primary Care)


Refer to
Electrophysiology
centre for ablation
therapy, if
appropriate


                                               6 months post procedure Follow-Up (NICE, 2006)
                                                           BHF Arrhythmia Nurse
                                                      Is the Patient in Sinus Rhythm?
           6 months post procedure Follow-Up (NICE, 2006)
                       BHF Arrhythmia Nurse
                  Is the Patient in Sinus Rhythm?
           Yes                                        No




Discharged to primary                 Depending on clinical indications and
care and advised to seek                  patient preference either:
medical attention if
symptoms recur                        1.   Re-attempt DC Cardioversion with
                                           amiodarone cover
                                      2.   Referral for ablation therapy
                                      3.   Rate control/Warfarin (primary
                                           Care)
          Guidance on Risk Assessment for
             Stroke Prevention in Atrial
              Fibrillation (GRASP – AF)
•   Prevalence of AF in primary care is 1.2% (England)
•   12,500 strokes per year are thought to be
    directly attributable to AF
•   Estimated annual cost of maintaining one
    patient on warfarin: £383
•   Estimated cost per stroke due to AF is
    £11,900 in the first year post stroke
    occurrence
        Guidance on Risk Assessment for
           Stroke Prevention in Atrial
            Fibrillation (GRASP – AF)
NICE estimate that 46% of patients that
should be on warfarin are not receiving it

Warfarin reduces risk of stroke by 64% in
   atrial fibrillation
Aspirin reduces the risk of stroke by 22% in
   atrial fibrillation
        Guidance on Risk Assessment for
           Stroke Prevention in Atrial
            Fibrillation (GRASP – AF)

The GRASP-AF Tool facilitates audit to
     identify high risk AF patients not on
     warfarin
It is a MIQUEST IT tool that can be freely
     downloaded from
     www.improvement.nhs.uk
         Guidance on Risk Assessment for
            Stroke Prevention in Atrial
             Fibrillation (GRASP – AF)

It can be used to identify patients in atrial
    fibrillation with a CHADS2 score of >1
The final report can exclude those with
    recorded contraindications to warfarin
                          Summary

•   Identify new atrial fibrillation/flutter – (include
    routine pulse checks at all appropriate consultations)
•   Refer to RAAF clinic (persistent), consultant
    (paroxysmal) or admit if acutely unwell
•   Rate Control and warfarin/aspirin in primary care
•   Patients will be reviewed with echocardiogram and
•   specialist clinic/consultant input
•   GRASP-AF Tool – opportunity to ensure practice
    population on evidence based stroke prophylaxis
    in atrial fibrillation – Potential to reduce
    morbidity/mortality and health costs
Over to You – Any Questions?

				
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posted:10/19/2011
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