Nice | Atrial fibrillation

This is the updated guideline from NICE on atrial fibrillation. This guideline is very different overall to the last guideline, but it probably doesn't contain anything radical if you've been to any AF teaching in the last couple of years.

As this is such a common problem, I've summarised the whole thing, mainly in the format of algorithms to follow, so hopefully these will be easy to refer to if needed.

Who is covered in this guideline?

Anyone with:

  • Atrial Fibrillation
    • Paroxysmal
    • Persistent (it has lasted more than 7 days, but is likely to be amenable to cardioversion treatment)
    • Permanent (where cardioversion has either not been tried, or has been tried and was unsuccessful).
  • Atrial Flutter
  • Anyone with an ongoing risk of arrhythmia after cardioversion

What should be the initial management of AF?

 

How do I calculate the CHA2DS2-Vasc Score?

The following comes from the ESC guidelines.
 

How do I calculate the Hasbled Score?

The following also comes from the ESC guidelines.

 
NICE doesn't really say anything about what to do with your HASBLED score, but at recent teaching I went to, they advised that a score of 3 or more indicated higher risk. However, even at this higher risk, mortality is still reduced by using anticoagulation, so you need to look at the individual case.

Should you rate or rhythm control?

The emphasis is now very much on rate control, though with some exceptions.

Drug treatment without cardioversion

Standard b-blocker (other than sotalol) first line
Dronedarone second line if the following criteria are met:
  1. AF not controlled by 1st line drugs
  2. After other options have been considered
  3. Have at least 1 of the following risk factors:
        • Hypertension needing drugs of at least 2 different classes
        • Diabetes Mellitus
        • Previous TIA / stroke / systemic thromboembolism
        • LA diameter ≥ 50mm
        • Age 70 or over
AND do not have left ventricular systolic dysfunction
AND do not have a history of, or current heart failure
Amiodarone third line if there is a risk of heart failure.
NB - flecainide and propafenone shouldn't be used.
Pill-in-the-pocket approach
  1. Where have infrequent paroxysms and few symptoms
  2. Known precipitants (eg alcohol / caffeine)
  3. Can understand when and how to use
  4. If they have
    1. No history of left ventricular dysfunction/valvular/IHD
    2. Systolic BP > 100 AND
    3. Resting heart rate > 70

What kind of anticoagulation should I use and what needs to be considered?

  • Explain to patients that generally the benefits of anticoagulation outweigh the risks.
  • Do not offer anticoagulation to people under the age of 65, whose sole risk is their sex.
  • Do not withhold anticoagulation just because someone is at risk of falls.

Choice of novel anticoagulant

This can be tricky. They all have specific criteria, which I have summarised in the below table. An 'X' means it can be used for that indication.
You obviously need to bear in mind local prescribing guidelines too and bear in mind that the newer agents are more expensive than warfarin.

How do you choose between the newer agents?

NICE side-steps this issue. Again, local teaching advised that they are much of a muchness, though the following are useful to bear in mind:
Dabagatrin 150mg is more effective than warfarin (110mg is equally effective), but is associated with more bleeds.There is better long term data for it than for the other newer agents. It has more side-effects than the others and you have to be careful with regards to renal function. It is twice daily dosing
Rivaroxaban is equally effective to warfarin and only needs once daily dosing.
Apixaban is more effective than warfarin, but has no more bleeds. It is twice daily dosing.
The Anticoagulation Decision Aid from the West Hampshire CCG is pretty good on all the details.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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