Management of atrial fibrillation

The following advice is based on: NICE CG180 Atrial Fibrillation: the management of atrial fibrillation (June 2014) and incorporates the following NICE Technology appraisals:

  • Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation.NICE TA249 (2012)
  • Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation. NICE TA256 (2012)
  • Apixaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation.NICE TA275 (2013)
  • Edoxaban for the prevention of stroke and systemic embolism in people with non-valvular atrial fibrillation NICE TA355 (2015)
  • Dronedarone for the treatment of non-permanent atrial fibrillation. NICE TA197 (2010)

The 2016 (4th Edition) guidance on Non-vitamin K oral anticoagulants for the prevention of stroke and systemic embolism in Atrial Fibrillation, published by the South West Cardiovascular Strategic Clinical Network.

MHRA Drug Safety Update (October 2019): Using the appropriate estimate of renal function to avoid the risk of adverse drug reactions

Also please refer to: Anticoagulation prescribing guidance

The recommendations apply to adults aged 18 years or over.

Patients with AF (and their carers) should be taught to recognise the signs of a stroke (the FAST test) and the action to be taken if they spot them

Information for prescribers in South Devon and Torbay

Commissioners in Devon are committed to maximising anticoagulation for appropriate patients as described in NICE CG180; and consider that the use of DOACs in all patients is not affordable. Prescribers in South Devon and Torbay have been asked to consider warfarin as the first-line agent, and consider apixaban, dabigatran, edoxaban, and rivaroxaban as second-line agents. Guidance regarding choice of oral anticoagulant for the treatment of non-valvular AF for prescribers working in South Devon and Torbay can be accessed here.

Nothing within this advice prevents prescribers in South Devon and Torbay from using DOACs where clinically appropriate, and the commissioners have indicated that this guidance does not detract from the obligations of the CCG to make all treatments available where guidance exists under a NICE technology appraisal.

Diagnosis and identification

AF can present in the setting of a wide variety of cardiac and non-cardiac conditions, it is often asymptomatic and can present with vague non-specific symptoms.

AF commonly occurs in association with risk factors, such as heart disease, and hyperthyroidism. Opportunistic assessment of such patients for the presence of AF may be prudent, especially since such patients are frequently seen for check-ups in primary care.

Other factors thought to cause or be associated with AF include medication such as thyroxine or bronchodilators, acute infection, electrolyte depletion, excessive caffeine intake or alcohol intake (especially in susceptible individuals, such as those with structural heart disease).

Perform manual pulse palpation to assess for the presence of an irregular pulse that may indicate underlying AF in people presenting with any of the following:

  • breathlessness/ dyspnoea
  • palpitations
  • syncope/ dizziness
  • chest discomfort
  • stroke/ transient ischaemic attack

Perform an electrocardiogram (ECG) in all people, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected.

In patients confirmed with a new diagnosis of Atrial Fibrillation (AF), NICE (2006) suggest select patients are referred for echocardiography, see western locality referral guideline

If heart rate causing haemodynamic compromise (low BP, heart failure, chest pain, dizziness, syncope), then refer for immediate hospital admission.

Rate or rhythm control?

A rate control strategy accepts the presence or occurrence of AF and aims to control ventricular rate and degree of irregularity despite continuing fibrillation within the atria. The alternative strategy of rhythm control attempts to restore and maintain sinus rhythm.

Refer people promptly at any stage if treatment fails to control the symptoms of AF and more specialised management is needed.

Rate control

Offer rate control as the first-line strategy to all people with AF, except people:

  • with AF which has a reversible cause
  • with heart failure thought to be primarily caused by AF
  • with atrial flutter whose condition is suitable for ablation surgery
  • for whom rhythm control strategy would be more suitable

For patients with newly diagnosed AF defined as new-onset within the last 24-48 hours, rate control medication should be considered first line in addition to the need for cardioversion guided by a specialist.

Adequate control is considered achieved when an individualised target heart rate leaves a patient asymptomatic.

Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences when considering drug treatment.

Offer a standard beta-blocker (other than sotalol*) or a rate-limiting calcium-channel blocker (diltiazem or verapamil**) as initial monotherapy.

*Sotalol should not be used for rate control due to risk of proarrhythmia

** Verapamil should only be combined with a beta-blocker (including eye drops) following specialist advice, due to the adverse effects on left ventricular function.

The combination of diltiazem with beta-blockers should be used with caution.

Consider digoxin monotherapy for people with non-paroxysmal AF only if they are sedentary. Digoxin is less effective for rate control during exercise or in conditions of high sympathetic drive (for example: infection or decompensated heart failure).

If monotherapy does not control symptoms (thought due to poor ventricular rate control), consider combination therapy with any 2 of the following:

  • a beta-blocker
  • diltiazem
  • digoxin

Do not offer amiodarone for long-term rate control.

Rhythm control

Consider pharmacological and/or electrical rhythm control for people with AF whose symptoms continue after heart rate has been controlled or a rate-control strategy has not been successful.

Cardioversion

For people having cardioversion, for AF that has persisted for longer than 48 hours, offer electrical rather than pharmacological cardioversion.

Consider amiodarone therapy starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm.

Prior to cardioversion anticoagulation must be considered.

Long term rhythm control

Assess the need for drug treatment for long-term rhythm control, taking into account the person's preferences, associated comorbidities, risks of treatment and likelihood of recurrence of AF.

If drug treatment for long-term rhythm control is needed, offer a standard beta-blocker (other than sotalol) as first-line treatment unless there are contraindications.

If beta-blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control.

Dronedarone (secondary care only) is recommended as an option for the maintenance of sinus rhythm after successful cardioversion in certain patients.

Amiodarone may be considered for patients with left ventricular impairment or heart failure.

Class 1c antiarrhythmic drugs such as flecainide or propafenone should not be offered to people with ischaemic or structural heart disease.

Where people have infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants (such as alcohol, caffeine), a 'no drug treatment' strategy or a 'pill-in-the-pocket' strategy should be considered. This should be offered following specialist assessment and the first such cardioversion should be supervised in secondary care.

Ablation

Ablation is reserved for consideration in patients in whom drug treatment has failed to control symptoms of AF or is unsuitable.

Assessment of stroke and bleed risk

AF increases the risk of stroke and thromboembolism by five-fold, but this risk is not homogeneous, and is dependent upon the presence of various stroke risk factors.

Assessment of stroke risk

Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:

  • symptomatic or asymptomatic paroxysmal, persistent or permanent AF
  • atrial flutter
  • a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm

Congestive Heart Failure or left ventricular dysfunction = 1

Hypertension History = 1

Age 75 years or greater= 2

Diabetes mellitus = 1

Stroke / TIA / previous thromboembolism = 2

Vascular disease history (myocardial infarction, peripheral artery disease, aortic plaque) = 1

Age 65-74 years = 1

Sex category: Female = 1 Male = 0

Assessment of bleeding risk

Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation. Offer modification and monitoring of the following risk factors:

  • uncontrolled hypertension
  • poor control of INR ('labile INRs')
  • concurrent medication, for example concomitant use of aspirin or an NSAID
  • harmful alcohol consumption

Hypertension history (uncontrolled, SBP>160 mmHg) = 1

Abnormal renal function or liver function = 1 point each

(dialysis, transplant, Cr greater than 2.6 mg/dL or greater than 200 µmol/L OR cirrhosis, bilirubin greater than 2 x upper limit of normal, AST/ALT/AP greater than 3 x upper limit of normal)

Stroke (previous history) = 1

Bleed history (prior major bleeding or predisposition to bleeding i.e. anaemia) = 1

Labile INRs (unstable/high INRs, Time in Therapeutic Range (TTR) less than 60%) = 1

Elderly (age over 65 years) = 1

Drugs or alcohol abuse = 1 point each

(medication predisposing risk of bleeding - antiplatelet agents, NSAIDs OR 8 drinks or more each week)

Risk versus benefit of anticoagulation

  • Discuss the benefits and risks of anticoagulation with the patient
  • Consider using the NICE patient decision aid: medicines to help reduce your risk of a stroke – what are the options?
  • Do not withhold anticoagulation solely because the person is at risk of having a fall
  • Do not offer stroke prevention therapy to people aged less than 65 years with AF and no risk factors other than their sex
  • For most people, the benefit of anticoagulation outweighs the bleeding risk
  • For people with an increased risk of bleeding, the benefit of anticoagulation may not always outweigh the bleeding risk. Careful monitoring of bleeding risk is important.
  • Taking HAS-BLED score into consideration:
    • Consider anticoagulation for men with a CHA2DS2-VASc score of 1
    • Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above

Anticoagulation in AF

Anticoagulation may be with warfarin, or a direct oral anticoagulant (DOAC) following consideration of bleeding risk see Assessment of stroke and bleed risk (above).

Refer patient for specialist management if anticoagulation is contraindicated or not tolerated.

Do not offer aspirin monotherapy solely for stroke prevention to people with AF. The NICE guideline concludes that the evidence is consistent with no clinical benefit of aspirin in reducing mortality and systemic emboli. The guideline also concludes that although there was a modest benefit in reducing ischaemic stroke it was partially offset by a modest harm in increased bleeding and haemorrhagic stroke. There is limited benefit in offering aspirin as the benefit is not outweighed by the associated harms; however this is based upon results from a single study which uses a dose different to that used in current clinical practice.

The decision about whether to start treatment with a DOAC should be made after an informed discussion between the clinician and the person about the risks and benefits of the various anticoagulant options. For people who are taking warfarin, the potential risks and benefits of switching to a DOAC should be considered in light of their level of INR control.

Each drug should be used according to the individual Summary of Product Characteristics (SPCs), however accumulated clinical experience in practice from physicians and pharmacists has moulded the South West Cardiovascular Strategic Clinical Network Non-vit K Anticoagulant guidance which has been used in order to provide the guidance below. The guidance sets out the main considerations and patient groups where these alternatives to warfarin may be useful.

MHRA Drug Safety Update (October 2019): Using the appropriate estimate of renal function to avoid the risk of adverse drug reactions

Efficacy and safety

The efficacy and safety of the DOACs in people unable or unwilling (for whatever reason) to take warfarin, or in whom warfarin is relatively or absolutely contraindicated, has not been conclusively established. All patients in the principal published studies (n >70,000) were eligible to be randomized to warfarin. There are still only small amounts of data on the safety and efficacy of DOACs in patients who have had previous serious bleeding or other adverse events with warfarin.

Clinical experience

There are no long term effectiveness data for DOACs beyond the approximate 2 year average in the published trials, and post-marketing safety studies are in progress. Warfarin has over 50 years of accumulated clinical experience.

Review

For people not taking an anticoagulant, stroke risk should be reviewed when the patient reaches 65 years of age or if any of the following develop at any age:

  • Diabetes
  • Heart failure
  • Peripheral arterial disease
  • Coronary heart disease
  • Stroke, TIA or systemic thromboembolism

For people who are not taking an anticoagulant because of bleeding risk or other factors, review stroke and bleeding risks annually.

For people who are taking an anticoagulant, review the continuing need for anticoagulation and the quality of anticoagulation at least annually or more frequently if clinically relevant events occur affecting anticoagulation or bleeding risk.

 

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