Excerpt

Atrial fibrillation (AF) is a very common problem. In England alone, approximately 835,000 people have AF.321 Through its effects on rate and rhythm, it is a major cause of morbidity. Through increasing susceptibility to stroke, it is a major cause of both morbidity and mortality.

Despite the fact that AF is a major population problem, it is not necessarily well managed. Anecdotally, people with AF often describe the inadequate explanations they have been given at the time of first diagnosis both concerning the nature of the problem and the treatment options which are open to them.

This may partly reflect the fact that many doctors, particularly those working in primary care, do not feel confident in AF management. Anticoagulation is a case in point. The 2006 atrial fibrillation NICE Guideline laid down criteria for anticoagulation – yet amongst patients with known AF, only 55% of those fulfilling the 2006 criteria for anticoagulant therapy currently receive it. Research into the shortfall in anticoagulant uptake indicates that it cannot be adequately explained by either bleeding risk or co-morbidities. The attitude of healthcare professionals and the perceived risk of anticoagulation could also be major factors limiting uptake.

The shortfall in the prescribing of anticoagulants to patients with AF was clearly seen in the Sentinel Stroke National Audit Programme of the Royal College of Physicians. Of 11,939 patients admitted with stroke to hospitals in England, Wales and Northern Ireland in the first 3 months of 2013, approximately one fifth were in AF on admission. Of these only 36% were receiving an anticoagulant. Yet 38% were on an antiplatelet drug as sole antithrombotic therapy and 26 % were on no antithrombotic treatment.

The rate and rhythm management of AF is also often perceived to be difficult. In discussions informing the scope of this guideline, the classification of AF into paroxysmal, persistent and permanent was considered to be a barrier to implementation of rate and rhythm care. While this classification is a natural sub-division which does help to inform management, it is important that it should not obscure the common underlying principles of heart rate and rhythm care which apply to the generality of AF patients.

This guideline seeks to address these issues. The question of how best to provide a patient with a focussed care package including patient information and treatment options is considered. Stroke prevention is considered in detail both in terms of treatment strategies, risk thresholds and risk scoring and options for treatment. Finally rate and rhythm management are considered, in as far as possible based on the totality of AF, rather than on individual sub-categories. In considering rate and rhythm management, it is emphasised that patient symptoms should be the driver to timely consideration of alternative escalating management options.

No clinical guideline can ever be complete and the constraints of the guideline process have meant that we have needed to focus on a number of specific areas. The current guideline is a partial update of the 2006 guideline. The evidence relating to some sections of the 2006 guideline, most particularly AF diagnosis, has not been updated and the original recommendations have been incorporated unchanged. It is also the case that there has been very rapid progress in a number of areas relating to AF in recent years. This has been reflected in recent NICE technology appraisals on dronedarone, dabigatran, rivaroxaban and apixaban. The evidence and the recommendations relating to these drugs have not been reconsidered in the current guideline. The existing technology appraisal recommendations have been incorporated into the updated guideline.

We have not sought to distinguish which aspects of care should take place in specific settings. We recognise that models of care vary greatly both locally and nationally and that in many places aspects of AF care which might hitherto have been regarded as most suited to secondary care are now being undertaken in primary care. It seems likely that this trend will continue. We have therefore tried to avoid imposing artificial boundaries. The target audience of the guideline is any healthcare professional working in any setting who is involved in caring for patients with AF.

Contents

• Guideline Development Group members
• Guideline Development Group co-optees
• Acknowledgements
• 1. Introduction
  • 1.1. Prevalence of AF
  • 1.2. Patient-centred care
• 2. Development of the guideline
  • 2.1. What is a NICE clinical guideline?
  • 2.2. Remit
  • 2.3. Who developed this guideline?
  • 2.4. What this guideline covers
  • 2.5. What this guideline does not cover
  • 2.6. Relationships between the guideline and other NICE guidance
• 3. Methods
  • 3.1.1. Amendments to 2006 text
  • 3.2. Developing the review questions and outcomes
  • 3.3. Searching for evidence
  • 3.4. Evidence of effectiveness
  • 3.5. Evidence of cost effectiveness
  • 3.6. Developing recommendations
• 4. Guideline summary
  • 4.1. Algorithms
  • 4.2. Key priorities for implementation
  • 4.3. Full list of recommendations
  • 4.4. Key research recommendations
• 5. Identification and assessment
  • 5.1. Presenting symptoms/pulse palpitation
  • 5.2. Electrocardiography
  • 5.3. Ambulatory ECG recording
  • 5.4. Echocardiography
• 6. Patient information and education
  • 6.1. Introduction
  • 6.2. Review question: What educational and behavioural interventions are clinically and cost effective for aiding the management of anticoagulation therapy, rate and rhythm strategies and symptoms in patients with AF?
• 7. Referral to specialist atrial fibrillation services
  • 7.1. Introduction
  • 7.2. Review question: What is the clinical and cost effectiveness of referral to specialist AF services?
• 8. Stroke risk tools
  • 8.1. Introduction
  • 8.2. Review question: What is the most clinically and cost-effective risk stratification tool for stroke or thromboembolic events in people with AF?
• 9. Antithrombotic therapy
  • 9.1. Introduction
  • 9.2. Review question: What is the most clinical and cost-effective antithrombotic therapy for stroke prevention in people with AF?
• 10. Bleeding risk tools
  • 10.1. Introduction
  • 10.2. Review question: What is the clinical and cost effectiveness of HAS-BLED compared to other tools in assessing bleeding risk in people with AF?
• 11. Monitoring
  • 11.1. Introduction
  • 11.2. Review question: What is the clinical and cost effectiveness of systematic monitoring of patients with AF?
• 12. Left atrial appendage occlusion
  • 12.1. Introduction
  • 12.2. Review question: What is the clinical and cost effectiveness of left atrial appendage occlusion (LAAO) compared to anti-thrombotic therapy in the prevention of stroke in people with AF?
• 13. Rate versus rhythm control
  • 13.1. Introduction
  • 13.2. Review question: What is the clinical and cost effectiveness of rhythm control (excluding ablation) compared to rate control in the treatment of AF in reducing stroke or improving prognosis?
• 14. Rate control strategies
  • 14.1. Introduction
  • 14.2. Review question: What is the clinical and cost effectiveness of using different rate control drug strategies in the pharmacological management of atrial fibrillation?
• 15. Restoration of sinus rhythm
  • 15.1. Introduction
  • 15.2. Review question: What is the most clinical and cost-effective means of (excluding ablation) restoring sinus rhythm (a) pharmacological cardioversion, (b) electrical cardioversion or (c) electrical cardioversion combined with antiarrhythmic drugs?
  • 15.3. Transoesophageal echocardiography-guided cardioversion
• 16. Maintenance of sinus rhythm
  • 16.1. Introduction
  • 16.2. Review question: What is the most clinical and cost-effective antiarrhythmic drug alone or in combination for maintaining sinus rhythm in (a) paroxysmal AF and (b) persistent AF after cardioversion?
  • 16.3. Treatment strategy for paroxysmal AF
• 17. Left atrial ablation
  • 17.1. Introduction
  • 17.2. Review question: What is the clinical and cost effectiveness of catheter ablation compared to non-ablation therapies in people with atrial fibrillation?
  • 17.3. Review question: What is the clinical and cost effectiveness of surgical ablation compared to non-ablation therapies in people with AF?
  • 17.4. Review question: What is the clinical and cost effectiveness of surgical ablation compared to left atrial catheter ablation in people with AF?
• 18. Pace and ablate
  • 18.1. Introduction
  • 18.2. Review question: What is the clinical and cost effectiveness of atrioventricular node ablation and pacing compared to usual care in the treatment of AF?
• 19. Acute atrial fibrillation (AF)
  • 19.1. People that are presenting acutely and either have new onset AF or destabilisation of their existing AF
  • 19.2. Review question: What is the clinical and cost effectiveness of using different rate control drug strategies in the pharmacological management of atrial fibrillation?
  • 19.3. Review question: What is the most clinical and cost-effective means of (excluding ablation) restoring sinus rhythm (a) pharmacological cardioversion, (b) electrical cardioversion or (c) electrical cardioversion combined with antiarrhythmic drugs?
  • 19.4. Antithrombotic therapy for acute-onset AF
• 20. Initial management of stroke and atrial fibrillation
• 21. Postoperative AF
  • 21.1. Drug prophylaxis for postoperative AF
  • 21.2. Treatment for postoperative AF
• 22. Reference list
• 23. Acronyms and abbreviations
• 24. Glossary
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Clinical article selection
  • Appendix E. Economic article selection
  • Appendix F. Literature search strategies
  • Appendix G. Clinical evidence tables
  • Appendix H. Economic evidence tables
  • Appendix I. Forest plots
  • Appendix J. Excluded clinical studies
  • Appendix K. Excluded economic studies
  • Appendix L. Cost effectiveness of stroke prevention strategies in patients with AF
  • Appendix M. Network Meta-analysis (NMA) of Antithrombotic therapy
  • Appendix N. Unit costs of pharmacological agents considered in the guideline
  • Appendix O. How this clinical guideline was updated
  • Appendix P. Research recommendations
  • Appendix Q. NICE project team
  • Appendix R. References
  • Appendix S. Atrial fibrillation guideline and appendices 2006 (CG36)

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.