NICE guidelines for AF

Question 1

What are the 4 steps in management of AF

Answer 1

1. Detection of AF
2. identifying the cause of AF (can this be treated)
3. Treating the arrhythmia itself- rate or rhythm control
4. reducing stroke risk- anticoagulation

Question 2

What is the aim in detection of AF

Answer 2

Aim is to reduce the prevalence gap

Question 3

when would you use a stroke risk assessment

Answer 3

use CHADSVASc score to assess stroke risk in people with any of the following
- symptomatic or asymptomatic paroxysmal, persistent or permanent AF
- atrial flutter
- a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm or catheter ablation

Question 4

when would you assess bleeding risk

Answer 4

assess bleeding risk when:
- considering starting anticoagulation in people with AF
- reviewing people already taking anticoagulation

Question 5

How do we calculate bleeding risk based on NICE guidelines

Answer 5

use ORBIT score because evidence shows that it has higher accuracy in predicting absolute bleeding risk than other bleeding risk tools

Question 6

What is the criteria of ORBIT score

Answer 6

1. Sex
2. haemoglobin less than 13mg/dL (2)
3. age greater than 74 years (1)
4. any history of GI bleeding, intracranial bleeding or haemorrhagic stroke (2)
5. GFR less than 60ml/min (1)
6. treatment with antiplatelet agents (1)

Question 7

give examples of modifiable risk factors to monitor bleeding risk

Answer 7

• Uncontrolled hypertension
• poor control of INR in patients on vitamin K antagonists
• concurrent medication, including antiplatelets, selective serotonin reuptake inhibitors and NSAIDs
• harmful alcohol consumption
• reversible causes of anaemia

Question 8

what should be discussed with the patient in terms of the benefits and risks of anticoagulation use

Answer 8

• for most people, the benefit of anticoagulation outweighs the bleeding risk
• for people with an increased risk of bleeding, the benefit of anticoagulation may not always outweigh the bleeding risk, and careful monitoring of bleeding risk is important

Question 9

What is the first line anticoagulation treatment

Answer 9

DOACs

Question 10

What is the second line anticoagulation treatment

Answer 10

warfarin
- consider switching to DOAC
- if direct acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with AF, offer a vitamin K antagonist

Question 11

Describe the steps in initiating DOACs

Answer 11

1. check the patient has non valvular AF
2. Check CHADSVASc- offer anticoagulation is greater or equal to 2
3. Ensure no contraindications to therapy
4. Check:
   - bloods for renal function, LFTs, clotting and FBC
   - bodyweight
   - CrCl
5. check bleeding risk with HASBLED or ORBIT
6. shared decision making- agar which DOAC to initiate and correct choice of dose
7. counsel patient and agree a plan for follow up including monitoring blood tests