New Atrial Fibrillation/Flutter Pathway and GRASP Tool

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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

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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

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New Onset Atrial Fibrillation or Flutter Is the
patient acutely unwell?
 
 
No
Yes
Primary Care 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
Admit to Hospital    
NEED FURTHER ADVICE? CONTACT BHF ARRHTYHMIA
NURSE 01305 254920  
 

• Box A Rate control
• First Line
• 1. Beta-blocker (e.g. Bisoprolol) or a rate
  limiting calcium antagonist (e.g. Diltiazem), if
  beta-blocker contraindicated
• 2. Digoxin additional to optimise rate control,
  where required. As monotherapy only in
  predominantly sedentary patients.
• NICE (2006)

Persistent Fax referral to Rapid Access Atrial
Fibrillation/Flutter Clinic. (Form attached.
Also available on Dorset County Hospital intranet
or by contacting BHF Arrhythmia Nurse)
Paroxysmal Refer to cardiology team in the usual
way.
 
 Rapid Access Atrial Fibrillation/Flutter Clinic
  Cardiologist
                                     
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• Rapid Access
• Atrial Fibrillation/Flutter Clinic
• ONE STOP
  APPOINTMENT
• (WITHIN 4 WEEKS OF REFERRAL)
•  
•  
• ECHO AND ECG
• BHF ARRHYTHMIA NURSE CLINIC
• q       Review history, symptoms, test and
  examination results
• q       Patient education
• q       Agree treatment plan DC Cardioversion or
  Rate Control
• q       Arrange ongoing follow-up, where required

Cardiologist input into RAAF clinic. Also
patients referred for DC Cardioversion from
cardiology clinic or in-patient stay.
  Cardiologist
Primary Care Manage long-term warfarin and
rate-control
BHF Arrhythmia Nurse Specialist Arrange DC
Cardioversion
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Prepare for DC Cardioversion Weekly INR (Target
2.5-3.0), must have INR gt2.0 for four full weeks
prior to DC Cardioversion (see next page)

• DC Cardioversion BHF ARRHYTHMIA NURSE/DAY
  SURGERY UNIT
• Procedure
• Review of medications and treatment
  pre-discharge
• (Cardiology Specialist Registrar
  and BHF Arrhythmia Nurse)
• 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.

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4 Weeks post procedure Follow-Up (NICE, 2006)
BHF Arrhythmia Nurse Is the Patient in Sinus
Rhythm?
YES
NO
Yes/No

• Cardiology Review
• Patient remains symptomatic despite adequate
  rhythm or rate control.
• Other cardiac complications are revealed.

• Depending on clinical indications
• and patient preference either
• Re-attempt DC Cardioversion with amiodarone cover
• Refer for ablation therapy
• 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?
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6 months post procedure Follow-Up (NICE, 2006)
BHF Arrhythmia Nurse Is the Patient in Sinus
Rhythm?
Yes
No

• Depending on clinical indications and patient
  preference either
• Re-attempt DC Cardioversion with amiodarone cover
• Referral for ablation therapy
• Rate control/Warfarin (primary Care)

Discharged to primary care and advised to seek
medical attention if symptoms recur
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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

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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

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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

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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 gt1
• The final report can exclude those with recorded
  contraindications to warfarin

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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

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Over to You Any Questions?