Cardiovascular System

Diagnosing atrial fibrillation (AF) is a crucial step in stroke prevention. AF may be symptomatic or asymptomatic, and can be persistent or paroxysmal. If atrial fibrillation is suspected, perform manual pulse palpation to check for an irregular pulse. This should be considered for people presenting with any of the following:

• Breathlessness
• Palpitations
• Syncope or dizziness
• Chest discomfort
• Stroke or transient ischaemic attack (TIA)

Perform a 12-lead electrocardiogram (ECG) to make a diagnosis of atrial fibrillation if an irregular pulse is detected in people with suspected atrial fibrillation with or without symptoms.

Once AF is detected starting patients on appropriate anticoagulation is the next key step in effective management. Two-thirds of strokes can be avoided through timely and appropriate initiation of an oral anticoagulant (OAC). Risk stratification and clinical decision-making tools have been developed and validated in order to help:

• Determine an individual’s thromboembolic risk and whether an OAC is clinically indicated.
• Determine how best to mitigate against bleeding complications.

CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk, Calculates stroke risk for patients with atrial fibrillation. CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk

Interpretation and application of the CHA₂DS₂-VASc Score

• Score < 0 men or <1 women= OAC is not recommended.
• Score = 1 men or 2 women= OAC should be considered.
• Score ≥ 2= OAC should be offered.

ORBIT Bleeding Risk Score for Atrial Fibrillation, Predicts bleeding risk in patients on anticoagulation for AF, ORBIT Bleeding Risk Score for Atrial Fibrillation

NICE NG196 suggest the use the ORBIT bleeding risk score because evidence shows that it has a higher accuracy in predicting absolute bleeding risk than other bleeding risk tools.

Provide ongoing monitoring and support to help reduce bleeding risk by addressing factors such as:

• Uncontrolled hypertension
• Poor INR control in patients taking vitamin K antagonists
• Concomitant medicines, including antiplatelets, selective serotonin reuptake inhibitors (SSRIs), and non-steroidal anti-inflammatory drugs (NSAIDs)
• Harmful alcohol use
• Reversible causes of anaemia

Decision support tool: making a decision about further treatment for atrial fibrillation, This decision support tool is to help with decisions about atrial fibrillation. It includes information about the condition and possible treatments. NHS_Atrial_Fibrillation_decision_tool

Optimising ongoing care in atrial fibrillation  ensures that patients receive holistic, high-quality management beyond anticoagulation. This includes using the correct dose of anticoagulant, with renal function monitored regularly in line with best practice guidance. Routine follow-up should also focus on modifying bleeding risk factors, managing comorbidities such as hypertension and heart failure, and supporting lifestyle changes - including weight loss and alcohol reduction.

• SPS DOAC Monitoring Advise, using Cockcroft and Gault is recommended for calculating creatinine clearance for DOACs. Estimated glomerular filtration rate can overestimate renal function and increase risk of bleeding events, DOACs (Direct Oral Anticoagulants) monitoring – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice

• Understand and managing DOAC interactions: It is important to understand the risks, mechanisms of interactions and actions to take when prescribing medicines with DOACs. Interactions with DOACs often arise when medicines increase or decrease the activity of CYP450 enzymes or P-gp. See SPS article for further information: Understanding direct oral anticoagulant (DOAC) interactions – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice

1. Adults with non‑valvular atrial fibrillation and a CHA₂DS₂-VAS_C stroke risk score of 2 or above are offered anticoagulation.
2. Adults with atrial fibrillation are not prescribed aspirin as monotherapy for stroke prevention.
3. Adults with atrial fibrillation taking a vitamin K antagonist who have poor anticoagulation control have their time in therapeutic range (TTR) recorded at each visit for INR assessment.

Reassess anticoagulation for a person whose anticoagulation is poorly controlled shown by any of the following:

• 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months
• 2 INR values less than 1.5 within the past 6 months
• TTR less than 65%.

• Patient Resources
  • British Heart Foundation: Understanding Atrial Fibrillation
  • West of England AHSN: Overview_of_AF
  • Arrhythmia Alliance: Know Your Pulse
  • Wessex AHSN: Starting Anticoagulation with Jack | AF Toolkit
• Clinician Resources
  • Eclipse VISTA Pathway, NHS Pathways