My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at the NICE guidelines: “Atrial fibrillation: diagnosis and management” (NG196), as well as the Clinical Knowledge Summaries (CKS) on diagnosis of AF and management of AF, both last updated in March 2023. I have summarised the guidance from a Primary Care perspective.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 
• 
  

The full NICE Guideline on “Atrial fibrillation: diagnosis and management” [NG196] can be found here:

·      Overview | Atrial fibrillation: diagnosis and management | Guidance | NICE

Also

The Clinical Knowledge Summary on “When should I suspect atrial fibrillation and how do I confirm the diagnosis? (Last revised in March 2023) can be found here:

·      Diagnosis of atrial fibrillation | Diagnosis | Atrial fibrillation | CKS | NICE

Also

The Clinical Knowledge Summary on “Management of AF” (Last revised in March 2023) can be found here:

·      Scenario: Management of AF | Management | Atrial fibrillation | CKS | NICE

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]  

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

• Free Download / Stream: https://alplus.io/halfway-through 

Transcript  

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Some of you have asked me to do more cardiovascular topics so, today, we'll be looking at the NICE guidelines on atrial fibrillation, also known as AF, specifically from a primary care perspective. Proper management of AF is very important, which is why I'm enthusiastic about sharing the most recent evidence-based recommendations from NICE, which were updated as recently as March 2023. However, please note that I'm here to provide information and interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

By the way, please make sure to stay for the entire episode, as I'll be sharing fictitious clinical cases created by chat GPT that will illustrate how the guideline is applied in real-life situations.

By the way, I will be sharing fictitious clinical cases created by chat GPT in the next video, that will illustrate how the guideline is applied in real-life situations. I have not included them in this video to avoid making it too long. However, the next video will not take long so subscribe in order not to miss it!

Remember that my summary is a very simplified version of the guideline. I have put links to the full guidance in the episode description.

So, with that said, let's dive in!"

Let’s start by saying that we are going to address three clinical areas today: the diagnosis, management and annual review of a patient with AF.

One of the first steps in detecting AF is performing a manual pulse palpation. We should do this if a patient presents with symptoms such as breathlessness, palpitations, syncope or dizziness, chest discomfort, or a history of stroke or TIA.

If an irregular pulse is detected, the next step is to perform an ECG, which will help confirm the presence of AF. However, in cases where paroxysmal AF is suspected but is undetected by an ECG, it may be necessary to offer additional testing with ambulatory ECG monitors, event recorders, or other ECG technologies for an appropriate period of time to capture episodes of AF.

Assessing stroke and bleeding risks is crucial in managing AF. To assess stroke risk, we should use the CHA2DS2-VASc stroke risk score. Evaluating bleeding risk is equally important and we should use the ORBIT bleeding risk score. These two tools guide decisions regarding anticoagulation therapy.

The CHA2DS2VASc score tool gives the following points:

• Congestive heart failure/left ventricular dysfunction = 1
• Hypertension (BP>140/90 or on treatment) = 1
• Age 75 years or older = 2
• Diabetes mellitus = 1
• Stroke/TIA = 2
• Vascular disease (prior MI, PVD, or aortic plaque) = 1
• Age 65–74 years = 1
• Sex category (female) = 1

The ORBIT scoring tool gives

• 2 points for:
• Low Hb or HCT (Males Hb <130 g/L or HCT <40% and females <120 g/L or <36%)
• History of bleeding (e.g., GI bleeding, or haemorrhagic stroke) 
• 1 point for:
• Age 74 or more
• eGFR of less than 60
• On antiplatelet treatment
• A score of 2 or less is considered low, 3 medium and 4 or more high.
• 
  

We should see if modifying risk factors for bleeding is possible. This can include addressing uncontrolled hypertension, avoiding concurrent use of aspirin or nonsteroidal anti-inflammatory drugs, minimizing alcohol consumption, and treating reversible causes of anaemia. 

Now, let's talk about the management of AF.  

For all people with AF (including paroxysmal AF):

• We will admit urgently if:
• There are signs and symptoms of haemodynamic instability such as a rapid pulse (greater than 150 beats per minute) and/or low blood pressure (e.g. a systolic blood pressure less than 90 mmHg), as well as symptoms like severe dizziness or syncope, chest pain, or breathlessness. Also be aware that electrical cardioversion may be recommended if the onset of AF is within 48 hours.
• Or we should also consider admission if they are unwell due to another serious associated or underlying condition.
• In new onset AF (of less than 48 hours), we will seek urgent secondary care advice to manage both arrhythmia and anticoagulation (because the latter may involve heparin) and this may also involve sending the patient to the emergency department

It's also important to assess for underlying causes of AF.

These can include:

• Cardiac causes, such as hypertension, valvular heart disease, heart failure, and ischaemic heart disease —for this we will arrange an ECG and consider transthoracic echocardiogram if there is a high risk or suspicion of underlying structural heart disease (such as a heart murmur) or functional heart disease (such as heart failure).
• Respiratory causes, such as chest infection or lung cancer — we will arrange a chest X-ray if lung pathology is suspected.
• Systemic causes, such as excessive alcohol intake, hyperthyroidism, electrolyte depletion, infection, or diabetes mellitus — we will use our clinical judgement to determine the need for blood tests such as a full blood count, liver, renal and thyroid function tests, calcium, magnesium, and glucose
• In summary: We will normally do an ECG, a CXR, blood tests and possibly an echocardiogram depending on the circumstances.

Once an underlying cause is identified, it is essential to manage it whenever possible. Referral to a cardiologist may be necessary, especially in cases of valvular heart disease or suspected heart failure.

However, we will need to refer to a cardiologist for rhythm control (that is, either pharmacological or electrical cardioversion), if:

• The AF has a reversible cause (for example a chest infection).
• There is Heart failure that is caused, or worsened, by AF.
• There is atrial flutter suitable for ablation
• or any other patient for whom rhythm‑control would be more suitable using our clinical judgement. 

Looking at the management in Primary care, the first thing that we need to do is to assess their stroke and bleeding risks using the CHA2DS2VASc and the ORBIT bleeding risk tools, reviewing and managing any modifiable risk factors for bleeding

We will offer anticoagulation with a direct-acting oral anticoagulant (also known as a DOAC) if a CHA2DS2VASc score of 2 or above, and consider a DOAC for men with AF and a CHA2DS2VASc score of 1. 

• Apixaban, dabigatran, edoxaban and rivaroxaban are suitable options.
• We will not offer anticoagulation for lower scores, that is a CHA2DS2VASc score of 0 for men or 1 for women.
• And we will not withhold anticoagulation solely because of a person's age or their risk of falls.

In people with new‑onset AF, if there is uncertainty over the precise time since onset, we will offer oral anticoagulation.

• If DOACs cannot be given, we will offer a vitamin K antagonist, like warfarin.
• However, for those already taking warfarin we will discuss the option of switching treatment.

And we will definitely not offer aspirin solely for stroke prevention in atrial fibrillation. For guidance on antiplatelet therapy for people who have had a myocardial infarction and are having anticoagulation, there are separate guidelines. We will not cover it here because the decision should rest with their cardiologist in secondary care. 

In Primary care, we will also need to look at the arrhythmia management. For most individuals with AF, a rate-control treatment is offered as the first-line approach. This can involve using a standard beta-blocker (but not sotalol) or a rate-limiting calcium-channel blocker, such as diltiazem or verapamil. The choice of medication depends on the person's symptoms, heart rate, comorbidities, and personal preferences.

In some cases, digoxin may be considered as an alternative for those with non-paroxysmal AF who do little or no exercise or when other rate-limiting drug options are not suitable. However, we will not offer amiodarone for long-term rate control.

If there is concomitant heart failure, we will follow the guidelines for chronic heart failure in managing their condition.

We will need to arrange follow-up within 1 week of starting treatment to review symptoms, heart rate, and blood pressure. 

In terms of patient education, we will need to provide information to the patient on:

• AF and Stroke awareness 
• Flying — advising that there are no flying restrictions provided AF is stable.
• Driving — advising that they must inform the driving Licensing Agency and to check their driving insurance still covers them.

After having looked at the diagnosis and initiating treatment, we are now going to look at the regular follow-ups or reviews that are needed. It is recommended to review patients at least annually if the symptoms are controlled or more frequently if necessary, using our clinical judgement to determine the appropriate intervals.

During the reviews, we will do the following:

We will check for symptoms of AF at rest and during exercise, and assess the heart rate.

• Criteria for rate control vary with age, and it is suggested that ventricular rate should be controlled between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise
• Review the person's rate control drugs and if the person cannot tolerate it, we will prescribe an alternative.

For people taking a rate-control treatment who have persistent symptoms of AF or a fast heart rate, we will consider one of the following options:

• If they are not taking the maximum drug dose, we will consider increasing the dose
• If they are taking the maximum drug dose, we will consider combination treatment with any two of the following drugs: a beta-blocker, digoxin, or diltiazem. We will seek specialist advice before prescribing diltiazem with a beta-blocker because bradycardia, atrioventricular block, asystole, or sudden death can occur with concurrent use.
• If symptoms are not controlled by combination treatment, we will refer to a cardiologist promptly, that is, to be seen within 4 weeks.

For people who have received a rhythm-control treatment in secondary care who have recurrent or persistent symptoms, we will refer back to a cardiologist for further assessment. 

We will also reassess the person's stroke risk using the CHA2DS2VASc assessment tool and bleeding risk (using the ORBIT score tool) at least annually. Stroke risk should also be routinely reviewed when a person reaches 65 or years of age, or if at any age they develop diabetes, heart failure, peripheral arterial disease, coronary heart disease, stroke, transient ischaemic attack, or systemic thromboembolism.

• For people not already taking an anticoagulant, we will offer treatment if they have a CHA2DS2VASc score of 2 or more, and we will consider offering anticoagulation treatment to men with a CHA2DS2VASc score of 1.
• For people already taking an anticoagulant:
• we will not stop anticoagulation solely because atrial fibrillation is no longer detectable — we will base the decision on a reassessment of CHA2DS2-VASc and ORBIT.
• we will review and manage any modifiable risk factors for bleeding.
• we will review anticoagulant therapy, including possible new drug interactions and we will do a FBC, liver and renal function tests at least annually or more frequently if clinically indicated.
• For people with persistent poor anticoagulation control on warfarin, we will consider switching to a DOAC such as apixaban, edoxaban, dabigatran, or rivaroxaban).
•  

For people taking rhythm control drugs that were initiated in secondary care, we will carry out any required monitoring. For amiodarone for example, this includes 6 monthly blood tests and an annual ECG and eye examination. 

And we will assess and manage their CVD risk and any possible complications of AF, including stroke and thromboembolism, heart failure and reduced quality of life.

Right, this is the summary of the guideline. (pause)

 Now, let’s have a look at some fictitious clinical cases created by chat GPT:

Case 1

The first patient is Emily Thompson who is 62 years old.

And has a BP of 130/80 mmHg

Emily has a history of hypertension and hypercholesterolemia. Additionally, Emily was diagnosed with type 2 diabetes five years ago and is currently on the following medication:

·      Amlodipine 5mg once daily

·      Atorvastatin 20mg once daily

·      Metformin 1000mg twice daily

Emily consults you because she experiences occasional episodes of palpitations and breathlessness. She has also reported intermittent dizziness over the past few months. She has not experienced any stroke or TIA symptoms.

What should we do? 

We should suspect AF and therefore we should perform a manual pulse palpation. This detects an irregular pulse.

What diagnostic steps should we take?

1.    We should do an ECG to confirm the presence of AF. However,

2.    If paroxysmal AF is suspected but undetected by the initial ECG, an ambulatory ECG monitor, event recorder, or other ECG technology should be used. This will allow continuous monitoring over a specific period to capture intermittent or infrequent episodes of AF. We should also consider this if the manual pulse palpation was normal but we remain suspicious. 

Case 2

The second patient is John Anderson who is 65. His BP is 140/90 and his pulse rate is 96.

He has a Medical History of Hypertension, hypercholesterolaemia and Valvular Heart Disease

John is currently taking an ACE inhibitor (lisinopril 20 mg OD), a calcium channel-blocker (amlodipine 10 mg BD) and a statin (atorvastatin 20 mg OD).

John presents with symptoms of AF that have only just started in the last day or two and AF has been confirmed with an ECG.

How should we manage him?

1.    We should firstly assess for signs and symptoms of hemodynamic instability: for example, a rapid pulse of 150 beats per minute or more and low blood pressure, e.g. a systolic blood pressure 90 or less. If he exhibits these symptoms, he should be admitted urgently. Luckily, John’s pulse rate is 96 and his BP is 140/90.

2.    However, we should get urgent secondary care advice, given that John's AF seems to have been present for less than 48 hours. This is recommended to address the management of both the arrhythmia and anticoagulation. John may or not be suitable for electrical or pharmacological cardioversion and the initial anticoagulation may involve the use of heparin. This may still require sending him to the emergency department to be fully assessed.

3.    In addition, we should expect the cardiologist to carry out further assessment of possible underlying causes of AF. Since John has a history of valvular heart disease, it is likely that this is contributing to his AF. A transthoracic echocardiogram can be considered to assess any valvular heart disease progression in addition to a CXR and basic blood tests, including a full blood count, liver and renal function tests, thyroid function tests, calcium, magnesium, and glucose levels. 

In summary, the recommended management approach includes evaluating signs of hemodynamic instability, assessing for underlying causes (cardiac, respiratory, and systemic), conducting necessary tests (ECG, CXR, blood tests, and echocardiogram), and seeking urgent secondary care advice given that the onset of AF is within 48 hours.

Case 3

The third patient is Peter Richardson who is 76

His Blood Pressure is 135/85 mmHg and his pulse rate is 78

Peter has a Medical History of hypertension, hyperlipidaemia and an MI ten years ago.

Peter takes lisinopril (10 mg once daily), atorvastatin (80 mg once daily) and clopidogrel (75 mg once daily) as part of his post-MI regimen.

He has been found to have AF on incidental screening, confirmed by an ECG. He has no symptoms and initial assessment includes a normal CXR and blood tests. A non-urgent echocardiogram has been requested as a precaution but he does not have a heart murmur or symptoms of cardiac failure so there is a low suspicion of structural heart disease.

Because of his age and being asymptomatic, after discussion and agreement with the patient and, perhaps after discussion with secondary care, it was decided that he would be managed in primary care and that referral for rhythm control / cardioversion was not appropriate for him. 

How should we assess and manage him further?

• We should assess his Stroke Risk. Using CHA2DS2VASc, the score is 4 (because of age over 75, HTA on treatment and previous vascular disease), indicating a high risk of stroke.
• Using the ORBIT bleeding risk tool, his score is 2 (because of age >74 and taking antiplatelet therapy) so his risk of bleeding is low.
• Considering his CHA2DS2VASc score of 4 and low bleeding risk, Peter is a suitable candidate for anticoagulation. We should always consider modifiable risk factors for bleeding but given that clopidogrel was given for his previous MI, we would need to seek advice from his cardiologist about this.
• As Peter’s exact time of onset of AF is uncertain, oral anticoagulation is recommended.
• We have the options of apixaban, dabigatran, edoxaban, and rivaroxaban, and we decide to prescribe apixaban (5 mg twice daily). If there was a problem with a DOAC, a vitamin K antagonist such as warfarin could be an alternative.
• We should also start him on rate-control treatment, such as a beta-blocker or a rate-limiting calcium-channel blocker. Given his previous history of MI, he is started on a betablocker. Because he has no symptoms and his BP is normal, we could give him a small dose of bisoprolol 1.25 mg daily which can be increased as necessary.
• We should arrange a follow-up appointment within 1 week of starting treatment to assess his symptoms, heart rate, and blood pressure.
• We should also offer Patient Education, including information about AF and Stroke awareness, flying (saying that there are no restrictions if AF is stable), driving (advising him to inform the driving licensing agency and to check his insurance cover), and the need for annual review.

Case 4 

The fourth and final patient is Sarah Johnson, aged 62

Her Blood Pressure is 130/80 mmHg

And her Medical History includes known atrial fibrillation. Although the AF was diagnosed five years ago, recently she has been experiencing some AF symptoms in the form of intermittent palpitations, and occasional shortness of breath. She also has a history of hypertension and well-controlled type 2 diabetes. Sarah had a transient ischemic attack (TIA) two years ago but has not experienced any recurrent episodes since then.

Her medication includes a beta-blocker, atenolol 100 mg daily, to control her heart rate, which is the maximum recommended dose. She also takes an anticoagulant, rivaroxaban 20mg OD, to reduce her risk of stroke. In addition, Sarah takes metformin 500 mg BD for her diabetes management and amlodipine 5 mg OD for blood pressure control.

She comes to see you for her annual review.

What should we do during this review?  

1.    During the annual review, Sarah's symptoms of AF should be assessed, both at rest and during exercise. Her heart rate should be monitored to ensure rate control. It is recommended to maintain her ventricular rate between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise.

2.    The review should include an assessment of Sarah's current medications. Since she is experiencing persistent symptoms of AF, despite taking the maximum dose of atenolol, we should consider combination treatment with an additional rate-control drug, such as digoxin or diltiazem. Sarah is still active and does regular exercise and therefore digoxin is not felt to be appropriate. Therefore, before prescribing diltiazem with a beta-blocker, specialist advice should be sought due to potential complications.

3.    Sarah's stroke and bleeding risks should also be reassessed using CHA2DS2VASc and ORBIT. These assessments should be conducted annually, but particularly when she reaches the age of 65 or if she develops any new conditions related to cardiovascular health.

4.    As Sarah already has a high stroke risk with a CHA2DS2VASc score of 4 (because of a previous TIA, hypertension and being female), she should continue her anticoagulation treatment with rivaroxaban. We should monitor it, checking for possible new drug interactions and conducting blood tests including a FBC, liver and renal function tests. These assessments should occur at least annually or more frequently if clinically indicated.

5.    Sarah's modifiable risk factors for bleeding should also be reviewed and managed. Her BP is well controlled, she is not abusing alcohol and there are no other concerns in terms of anaemia or drug interactions.

6.    If Sarah were taking rhythm control drugs initiated in secondary care, for example amiodarone, we should arrange the required monitoring.  

In conclusion, the management of AF requires a comprehensive approach that addresses both the underlying causes and the patient's individual risk factors. We have discussed the importance of detection and diagnosis, the assessment of stroke and bleeding risks, management strategies, and regular reviews.

Please keep in mind that this is only a summary and my interpretation of the guideline.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye