Any patient with newly diagnosed atrial fibrillation should immediately be considered for oral anticoagulation according to the CHA2DS2-VASC risk score. This should not be deferred until Cardiology review.
Any patient with symptomatic atrial fibrillation can be referred to general cardiology to discuss further treatment options. It is often worthwhile starting a B Blocker (or rate limiting Calcium channel blocker) in Primary Care to control the ventricular rate and improve symptoms.
Asymptomatic, especially elderly, patients with longstanding or coincidentally discovered atrial fibrillation do not require referral. The need for oral anticoagulation and additional rate control agents (aim HR <100bpm) should be considered. See further information below.
Patients with atrial fibrillation where a rate control strategy is adopted do not require an echocardiogram unless there are other indications meriting echocardiography. See “referral for echocardiography” section for further information.
Addressing risk factors such as hypertension, alcohol excess, diabetes and excessive BMI are helpful in reducing episodes of AF and maintaining sinus rhythm.
Anticoagulation for NVAF:
Current NHS Lothian formulary currently recommends either Apixaban or Edoxaban as joint first-line anticoagulants to prevent thromboembolism in non-valvular atrial fibrillation (NVAF). Apixaban, Edoxaban and other direct oral anticoagulants (DOACs) are not licensed and are harmful in patients with either mitral stenosis or mechanical heart valves. These patients should be prescribed warfarin, with target INR that is determined by the type of valve replacement. See Lothian Joint Formulary for further information (link in Resources tab below).
Consider anticoagulation in males with a CHA2DS2-VASC score of ≥1 and females ≥2 (i.e. all females with one additional risk factor). There is no upper age limit to anticoagulation. Bleeding risk factors (HASBLED and ORBIT risk scores) help identify patients at higher risk of bleeding where modifiable bleeding risk factors should be addressed. These include hypertension, concomitant NSAID prescription and alcohol excess. Higher bleeding risk scores should not prevent anticoagulant administration but identifies patients where net clinical benefit from anticoagulation is less. The risk of falls alone should not discourage anticoagulant prescription.
C.W & C.S 16-01-23
Who to refer:
Any symptomatic patient with atrial fibrillation.
Any patient where a rhythm-control strategy may be warranted, especially very young patients.
Who not to refer:
Asymptomatic elderly patients with longstanding or coincidentally discovered AF
Consider patients for an oral anticoagulant according to CHA2DS2-VASC score and consider HASBLED or ORBIT risk scoring
Start B Blocker or rate limiting Calcium channel blocker if tachycardic or symptomatic
Address modifiable risk factors
Consider need for echocardiography referral (see referral for echocardiography section).
