Dr Tom McAnea describes key updates in the recommendations of the updated NICE guideline on diagnosis and management of atrial fibrillation

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Dr Tom McAnea

Read this article to learn more about:

  • a change in the tool recommended to assess the risk of bleeding in people with atrial fibrillation (AF)
  • anticoagulant treatment options for people with AF and a high risk of stroke
  • the importance of shared decision-making with patients.

Read this article online at: GinP.co.uk/456187.article

Atrial fibrillation (AF) is the most common sustained arrhythmia seen in UK general practice, with an estimated prevalence of 2.5% in England.1 In 2016, 1.4 million people in England were thought to be living with AF; of these, about 425,000 were believed to be undiagnosed and untreated.1 The potential sequelae of AF can be serious: it is estimated that AF causes one in five strokes in the UK.2

In April 2021, NICE published an updated guideline on the diagnosis and management of AF.3 It focuses on several areas where new evidence has become available since publication of the previous guideline in 2014. These include methods of identifying AF, the use of tools to assess the risk of stroke and bleeding, and anticoagulation. Given the potential scale of morbidity and mortality from this condition, the updated guideline is timely, and provides primary care clinicians with a clear approach to the diagnosis and management of AF.

Assessment and diagnosis

Manual palpation of the radial pulse should be used in the initial assessment of patients with suspected AF. This includes those who present with breathlessness, palpitations, dizziness, chest discomfort, stroke, or transient ischaemic attack (TIA). If an irregular pulse is detected in patients with suspected AF, a 12-lead electrocardiogram (ECG) should be performed.3

In many patients, AF can be paroxysmal and, therefore, it is missed on palpation of the pulse or on ECG. In these cases, use a 24-hour ambulatory ECG monitor if symptomatic episodes are less than 24 hours apart. If symptomatic episodes occur more than 24 hours apart, use an ambulatory ECG monitor or event recorder.3

Stroke risk

As in the 2014 guideline, the updated version recommends the use of the CHA2DS2-VASc score4 to assess stroke risk in patients who have symptomatic or asymptomatic AF (paroxysmal, permanent, or persistent), atrial flutter, or a continuing risk of recurrence after cardioversion or ablation.3

Bleeding risk

Bleeding risk should be assessed when considering starting anticoagulation in patients with AF, and when reviewing those already on this treatment. The updated guideline recommends the use of the Outcomes Registry for Better Informed Treatment (ORBIT) of AF bleeding risk score.3,5 This is a change from the 2014 guideline, which recommended the use of HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalised ratio), and is based on evidence that ORBIT has a higher accuracy in predicting absolute bleeding risk. The updated guideline recognises that other bleeding risk tools may need to be used while ORBIT becomes embedded into practice systems. It also recommends that patients should be offered support to modify risk factors for bleeding—for example hypertension, poor control of international normalised ratio, relevant medication, excess alcohol consumption, and anaemia.3

A patient-centred approach

When discussing the results of the stroke and bleeding risk assessments, the importance of a patient-centred approach is emphasised, which considers both the patient’s medical history and their preferences.3 A ‘personalised package of care’ is recommended, which takes into account stroke awareness, rate and rhythm control, psychological support, and education and information on AF and its management.3 Further guidance on enabling patients to take part in their care is provided in NICE Guideline 138, Patient experience in adult NHS services: improving the experience of care for people using adult NHS services.6

GPs should refer patients for a specialist opinion if treatment fails to control symptoms within 4 weeks, or after recurrence of AF following cardioversion.3

Anticoagulation

In terms of stroke prevention, patients should be advised that for most people the benefits of anticoagulation outweigh the bleeding risk. For those who have an increased risk of bleeding, this may not be the case, however, and careful monitoring is important in this group.3

Anticoagulation treatment options should be discussed with patients, taking into account their comorbidities—in particular, the use of direct-acting oral anticoagulants (DOACs) in those with a history of renal impairment.3 The risks and benefits of different drugs should be discussed, and NICE guideline recommendations on shared decision-making, medicines adherence, and medicines optimisation followed (see also: Incorporate shared decision making into everyday practice).3,7–9

Patients with AF and a CHA2DS2-VASc score of 2 or above should be offered treatment with a DOAC.3 Apixaban, dabigatran, edoxaban, and rivaroxaban are all recommended as options. The choice of anticoagulant should take into account the patient’s circumstances, and a NICE treatment pathway is available to assist in this decision.10

Men with AF and a CHA2DS2-VASc score of 1 or above should be considered for anticoagulation, taking into account their risk of bleeding. Apixaban, dabigatran, edoxaban, and rivaroxaban are all recommended as options.3

A vitamin K antagonist should be offered to patients if a DOAC is unsuitable, contraindicated, or not tolerated.Patients who are already taking a vitamin K antagonist and are stable should continue with their current treatment and discuss the option of changing agent at their next routine appointment.3

Patients aged under 65 years with AF and no risk factors other than their sex should not be offered anticoagulation.Anticoagulants should not be withheld because of a patient’s falls risk or their age.3

Aspirin should not be used solely for stroke prevention in patients with AF.3

Review and monitoring

Patients who are not taking an anticoagulant should have their stroke risk reviewed at the age of 65 years, or if they are diagnosed at any age with diabetes, ischaemic heart disease, heart failure, peripheral arterial disease, stroke, TIA, or thromboembolic disease.Those who are not taking an anticoagulant because of bleeding risk should be assessed annually to review their stroke and bleeding risks.3

For patients treated with an anticoagulant, review the need for and quality of the treatment at least annually, or more often if clinically indicated.3

Rate and rhythm control in non-acute settings

Rate control should be offered as the first-line treatment strategy except in people with reversible AF, AF caused by heart failure, new-onset AF, atrial flutter suitable for ablation, and those for whom a rhythm-control strategy would be more suitable.3

As initial rate-control monotherapy, patients should be offered:3

  • a standard beta-blocker (that is, one other than sotalol), or
  • a rate-limiting calcium channel blocker (diltiazem or verapamil). 

The drug choice should be based on symptoms, heart rate, comorbidities, and preferences.

In patients with heart failure and AF, calcium channel blockers should be avoided and beta-blockers are preferred.3,11

Digoxin can be offered as initial rate-control monotherapy for patients with non-paroxysmal AF if they do little or no exercise and/or if other drug options are not available because of comorbidities or preferences.3

If a single agent does not control the patient’s symptoms, consider using any two of the following in combination:3

  • a beta-blocker
  • diltiazem
  • digoxin.

Note that this is an off-licence use of diltiazem.

Amiodarone should not be used for long-term rate control.3

Anti-arrhythmic drug therapy is recommended as follows (no change from the 2014 guideline):3

  • a standard beta-blocker (that is, one other than sotalol) as first-line treatment
  • if beta-blockers are ineffective or contraindicated, consider an alternative treatment
  • amiodarone should be considered for patients with left ventricular impairment or heart failure.3

In practice, many patients requiring this treatment are likely to be referred to cardiology for ongoing management.

Patients who have few paroxysmal episodes and are relatively asymptomatic could consider a ‘pill-in-the-pocket’ strategy in which anti-arrhythmic drugs are taken only when they feel the need. Patients with paroxysmal AF could consider a ‘pill-in-the-pocket’ strategy if they:3

  • have no history of left ventricular dysfunction, ischaemic heart disease, or valvular disease
  • have a systolic blood pressure greater than 100 mmHg and a resting heart rate greater than 70 bpm
  • are able to understand how and when to take the treatment.

Acute presentation of AF

In practice, many patients who are symptomatic may present directly to emergency departments or be referred there. If they present in primary care and are haemodynamically stable, the guideline recommends that they are offered:3

  • either rate or rhythm control if the symptom onset is less than 48 hours
  • rate control if the symptom onset is more than 48 hours or is uncertain.

If patients present with suspected AF and symptoms or signs of heart failure, they should be referred for specialist assessment.

Anticoagulation should be offered to patients with a confirmed AF diagnosis of recent onset if:

  • sinus rhythm is not restored within 48 hours of symptom onset
  • there is a high risk of recurrence of AF because of history of failed cardioversion, structural heart disease, prolonged AF in the past (more than 12 months), or previous recurrences.

If there is uncertainty about the precise time of symptom onset, patients should be offered anticoagulation, as for persistent AF.

Stopping anticoagulation

In patients with a diagnosis of AF, do not stop anticoagulation solely because AF is no longer detectable. The decision to stop should be based on patient preference, clinical context, and use of the CHA2DS2 -VASc and ORBIT tools to determine stroke and bleeding risk.3

Summary

The updated guideline recommends a change in the preferred tool to assess the risk of bleeding in people with AF: ORBIT rather than the previously recommended HAS‑BLED.3 ORBIT was found to be more accurate than HAS-BLED in predicting absolute risk of major bleeding, both for people using vitamin K antagonists, such as warfarin, and those using DOACs. ORBIT was better calibrated at all levels of major bleeding risk, including higher levels. It was also better at predicting absolute risk of intracranial haemorrhage.3 

The guideline recognises that ORBIT does not include all of the modifiable risk factors included in HAS-BLED. The guideline committee considered that fully investigating modifiable risk factors is established clinical practice, regardless of the tool used.3 

Other new recommendations include requesting a 12‑lead ECG and using an ambulatory ECG monitor or event recorder to confirm diagnosis,3 which will already be standard practice in many primary care settings. 

The importance of assessing an individual patient’s circumstances and seeking shared decision making using available online decision aids and other resources is emphasised.3 Again, this will already be well‑established practice for many GPs. 

The recommendation to use a DOAC in men with AF and a CHA2DS2‑VASc score of 1 or above is new, as is considering switching patients from warfarin to a DOAC at the next routine review.3 

Choosing not to treat patients aged under 65 years with AF and no risk factors other than their sex with an anticoagulant is a further new recommendation. Not withholding anticoagulation based on age or falls risk is also new.3 

Overall, the updated guideline provides GPs with a clear approach to diagnosing and managing patients with this increasingly common and potentially life‑threatening condition. 

Dr Tom McAnea

GP Principal and Trainer, Programme Director Sheffield VTS, Clinical Director West 5 Care PCN

At the time of publication (September 2021), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

Key points

  • The preferred tool to assess the risk of bleeding in people with AF is ORBIT, rather than the previously recommended HAS-BLED
  • Request a 12-lead ECG and use an ambulatory ECG monitor or event recorder to confirm an AF diagnosis; this will already be standard practice in many primary care settings
  • A patient-centred approach is needed for discussing the results of stroke and bleeding risk assessments, with consideration for both medical history and patient preference
  • A ‘personalised package of care’ is recommended, which takes into account stroke awareness, rate and rhythm control, psychological support, and education and information on AF and its management
  • Use a DOAC in men with AF and a CHA2DS2-VASc score of 1 or above
  • Consider switching patients from warfarin to a DOAC upon routine review
  • It is not necessary to treat patients aged under 65 years with AF and no risk factors, other than their sex, with an anticoagulant
  • Do not withhold anticoagulation based on age or risk of falls

AF=atrial fibrillation; ORBIT=Outcomes Registry for Better Informed Treatment; HAS-BLED=Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalised ratio, Elderly, Drugs or alcohol; ECG=electrocardiogram; DOAC=direct oral anticoagulant

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Encourage palpation of the radial pulse as a screening process at every health contact to help identify asymptomatic AF
  • Ensure that local facilities are readily available to general practice for 12 lead ECG, 24-hour ambulatory ECG recorders, and event recorders to support diagnosis of fixed and paroxysmal AF
  • Encourage the use of the ORBIT bleeding risk score when assessing anticoagulation for stroke prophylaxis, and assess whether this can be built into local clinical software systems alongside the CHA2DS2-VASc tool
  • Update local formularies to indicate that DOACs are now the first-line choice for treatment of AF (although not in people with some prosthetic valve types) for those who meet the criteria for anticoagulation
  • Promote the review of patients currently prescribed vitamin K antagonists at structured medication reviews, and consider switching these patients to a DOAC where indicated and agreed.

STP=sustainability and transformation partnership; ICS=integrated care system; AF=atrial fibrillation; ECG=electrocardiogram; ORBIT=Outcomes Registry for Better Informed Treatment; DOAC=direct oral anticoagulant

Implementation actions for clinical pharmacists in general practice

written by Riad Choudhury, Clinical Services Manager, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.

  • Drive AF detection through opportunistic pulse assessments during vaccination clinics, and by running proactive searches to stratify patients at high risk of AF (this may include patients who are anticoagulant naïve, as well as those taking aspirin monotherapy)
  • Protect patients at risk of AF-related stroke through appropriate anticoagulation, blood pressure control, and cholesterol management
  • Perfect anticoagulant therapy by running anticoagulation clinics to review dosage in patients already prescribed a DOAC, optimising this where necessary, and by reviewing patients on warfarin who are transitioning to a DOAC as recommended by the updated NICE guidance
  • Support AF management and medicines optimisation by:
    • assessing stroke and bleeding risk (CHA2DS2-VASc and ORBIT scores)
    • assessing cardiac function
    • preventing stroke—for example, via anticoagulation
    • ensuring that the correct dose of anticoagulant is prescribed, taking into account patient factors—for example, renal function and weight 
    • transitioning patients from vitamin K antagonists to DOACs
    • minimising modifiable risk factors for bleeding
    • offering rate and rhythm control
    • supporting adherence to treatment 
    • providing education and counselling 
    • designing a personalised package of care and information.

The i2i Network has a suite of training and implementation resources, both bespoke and free, for GP clinical pharmacists, including e-learning and on-demand training by experts, covering a range of long-term conditions including AF. Become a free member at: i2ipharmacists.co.uk/

AF=atrial fibrillation; DOAC=direct oral anticoagulant; ORBIT=Outcomes Registry for Better Informed Treatment

References

  1. NICE. Atrial fibrillation: how common is it? NICE Clinical Knowledge Summary. Available at: cks.nice.org.uk/topics/atrial-fibrillation/background-information/prevalence (accessed 1 September 2021).
  2. Stroke Association. Atrial fibrillation: information and resources. www.stroke.org.uk/professionals/atrial-fibrillation-information-and-resources (accessed 29 July 2021).
  3. NICE. Atrial fibrillation: diagnosis and management. NICE Guideline 196. NICE, 2021. Available at: www.nice.org.uk/ng196
  4. Lip G. CHA₂DS₂-VASc score for atrial fibrillation stroke risk. www.mdcalc.com/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk (accessed 29 July 2021).
  5. O’Brien E. ORBIT bleeding risk score for atrial fibrillation. www.mdcalc.com/orbit-bleeding-risk-score-atrial-fibrillation (accessed 29 July 2021).
  6. NICE. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. Clinical Guideline 138. NICE, 2012 (updated 2021). Available at: www.nice.org.uk/cg138
  7. NICE. Shared decision making. NICE Guideline 197. NICE, 2021. Available at: www.nice.org.uk/ng197
  8. NICE. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. Clinical Guideline 76. NICE, 2009. Available at: www.nice.org.uk/cg76
  9. NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guideline 5. NICE, 2015. Available at: www.nice.org.uk/ng5
  10. NICE. Preventing stroke in people with atrial fibrillation. NICE Pathway. pathways.nice.org.uk/pathways/atrial-fibrillation#path=view%3A/pathways/atrial-fibrillation/preventing-stroke-in-people-with-atrial-fibrillation.xml&content=view-node%3Anodes-anticoagulation (accessed 29 July 2021).
  11. NICE. Chronic heart failure in adults: diagnosis and management. NICE Guideline 106. NICE, 2018. Available at: www.nice.org.uk/ng106