2. NICE 2014 Check pulse in patients presenting with:
breathlessness/dyspnoea
palpitations
syncope/dizziness
chest discomfort
stroke/transient ischaemic attack.

3. NICE Bullet Points Confirm rhythm – ECG
Echo – only if will alter management
Stroke risk / bleeding risk assessment
If VKA – monitor TTR
Rate control is first line Rx
Specialist referral: refer people promptly at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed.
Consider AF ablation if ongoing symptoms (Paroxysmal AF)
Consider PPM / Avnodal ablation if ongoing symptoms (Permanent AF)

5. NICE 2014 Stroke prevention
Do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2-VASc score of 0 for men or 1 for women). [new 2014]
No place for aspirin unless another indication eg IHD

7. NICE 2014 – Rate vs Rhythm
Offer rate control as the first-line strategy to people with persistent atrial fibrillation, except in people:
Reversible cause
Heart failure caused by atrial fibrillation with new-onset atrial fibrillation
Atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
A rhythm control strategy would be more suitable based on clinical judgment

10. General Management of the AF Patient
Secondary care 10

11. Conditions predisposing to, or encouraging progression of AF11

12. Initial management of AF
History (including alcohol intake), examination, blood tests, ECG.
Cardiac echo if murmur or very abnormal ECG or no predisposing cause.
Anticoagulant after calculating thromboembolic risk
Rate control agents
Treat any underlying conditions
Refer if severe haemodynamic compromise, poor rate control, complex heart disease or for consideration of cardioversion
Do not need hospital referral if fast AF but not severely compromised.

13. Rhythm Control vs Rate Control
NICE 2014 – Rate Control
Standard BB or rate control CCB
Dig as mono-RX only if sedentary
Combine agents as required
Do not use amiodarone
If fails – ablate & pace
Rate Control
Beta blockers
Verapamil/Diltiazem
Digoxin
Av V node ablation + Pacemaker

14. 45% BB alone 6% CCB alone 7% Dig alone 17% BB + Dig 3% BB + CCB
614 Perm AF
Strict (rest HR <80) Vs
Lenient AF (rest HR <110)
1-EP: CV death / HF admit / CVA / embolism / bleeding / life threatening arrhythmia
45% BB alone
6% CCB alone
7% Dig alone
17% BB + Dig
3% BB + CCB
5% CCB + Dig
1% BB + Dig + CCB
14.9% vs 12.9% at 3-years; NS

15. Rhythm Control vs Rate Control
Cardioversion
Class I Agents (ed flecainide)
Beta-blockers
Sotalol Class III Dose
Amiodarone
Direct AF Ablation
- PV Isolation
- LACA
NICE 2014 – Rhythm Control
Continued symptoms despite controlled rate
Recent onset and rhythm control likely to be successful
Amiodarone if bad LV
Amiodarone to consolidate DCCV
1c-Agent only if normal heart
PVI for PAF if drugs fail

16. Who to refer for cardioversion?
No clear guidelines
Symptomatic persistent AF < 12 months with no serious underlying heart disease
AF with precipitating cause eg thyrotoxicosis, chest infection now treated
Tachycardia induced cardiomyopathy
Chances lower with long duration of AF,large LA, mitral valve disease, class III or IV NYHA
Not if asymptomatic and age > 60