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Guideline calls for better treatment of atrial fibrillation

London Susan Mayor

Patients with an irregular pulse should undergo electrocardiography to improve the detection of atrial fibrillation, recommends a new guideline for the NHS in England. And patients with atrial fibrillation should be treated with antithrombotic drugs after formal risk assessment, to reduce the risk of preventable strokes associated with the condition, it says.

The guideline says it is important that atrial fibrillation—the commonest cardiac arrhythmia—is diagnosed early, because people with it have a one in 20 chance of stroke. To achieve early diagnosis it recommends electrocardiography for all patients in whom atrial fibrillation is suspected because of an irregular pulse, whether or not they have symptoms.

The guideline was drawn up by the National Collaborating Centre for Chronic Conditions, for the National Institute for Health and Clinical Excellence, the body that advises on use of treatments in the NHS in England.

Michael Rudolf, a consultant physician at Ealing Hospital, London, and chairman of the guideline development group, said, “Atrial fibrillation is a really common disorder. The prevalence doubles for every decade of ageing, affecting about 10% of people in their 80s.” A Scottish study of more than 15 000 people aged 45 to 64 years showed a prevalence of around eight per 1000 person years in men and five per 1000 person years in women across all the age groups, increasing with age (Heart 2001;86:516-21). The four year incidence of atrial fibrillation was 0.54 cases per 1000 person years, the study found.

“Every patient admitted to hospital with a stroke and atrial fibrillation represents a lost opportunity to prevent a stroke. It is important to diagnose AF [atrial fibrillation] much earlier and then to treat it effectively,” Dr Rudolf said. Use of automated blood pressure monitors has reduced opportunities to check patients’ pulses, he noted, and he said that it would be worth opportunistically monitoring pulses of patients who may be at risk of atrial fibrillation, including elderly people.

The guideline recommends that treatment with antithrombotics should be begun as quickly as possible in patients with newly diagnosed atrial fibrillation, if such treatment is not contraindicated. A simple stroke risk stratification algorithm should be used to assess patients’ risk of stroke and thromboembolism and to guide choice of thromboprophylaxis.

The evidence based recommendations also clarify use of treatments to control heart rate and heart rhythm—the main aims of treating atrial fibrillation, which have sometimes been seen as mutually exclusive. The guideline notes that some patients with persistent atrial fibrillation will satisfy criteria for an initial strategy of either controlling rate or controlling rhythm (for example, a patient aged over 65 who is also symptomatic). The potential advantages and disadvantages of each strategy should be explained to patients before it is agreed which should be adopted.

&bgr; blockers or rate limiting calcium antagonists are recommended as initial monotherapy in patients with permanent atrial fibrillation who need treatment for rate control. Bernard Higgins, director of the National Collaborating Centre for Chronic Conditions, said: “AF is too frequently treated with the almost automatic prescription of monotherapy with digoxin. This is still a useful drug over 200 years on but [is] the best option for only a minority of patients.” The guideline recommends that digoxin should be used as monotherapy only in patients who are predominantly sedentary.

Atrial Fibrillation: National Clinical Guideline for Management in Primary and Secondary Care is available at www.rcplondon.ac.uk.

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