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Patient care pathway, implementation and audit criteria for patients with atrial fibrillation
  1. M Davis1,
  2. S Rodgers2,
  3. M Rudolf4,
  4. M Hughes3,
  5. G Y H Lip5,
  6. on behalf of the Guideline Development Group for the NICE clinical guideline for the management of atrial fibrillation
  1. 1Moorfield House Surgery, Leeds, UK
  2. 2University College, London, UK
  3. 3National Collaborating Centre for Chronic Conditions (NCC-CC), Royal College of Physicians, London, UK
  4. 4Ealing Hospital NHS Trust, Southall, UK
  5. 5University Department of Medicine, City Hospital, Birmingham, UK
  1. Correspondence to:
    M Davis
    Moorfield House Surgery, 11 Wakefield Road Garforth, Leeds LS23 6SA, UK; Markdavisbspa{at}aol.com

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The patient care pathway maps the sequence of decisions that will be required to identify, assess, manage and monitor patients with atrial fibrillation (fig 1). The pathway also provides a “guide to the guideline” in that the decisions taken will be informed by the evidence base and recommendations of the full guideline document.

Figure 1

 Care pathway for diagnosing and treating atrial fibrillation. AF, atrial fibrillation; ECG, electrocardiogram.*Further management to include rate or rhythm control treatment strategy and appropriate antithrombotic therapy based on stroke risk stratification model.Further follow-up for co-existing conditions and assessment for ongoing anticoagulation.

Diagnosis

The guideline recommends that in patients presenting with breathlessness, palpitations, syncope, chest discomfort or stroke, pulse palpation should be carried out to determine the presence of an irregular pulse that may indicate underlying atrial fibrillation. Thus, the detection of patients with atrial fibrillation, especially those asymptomatic, will be enhanced by opportunistically checking the pulse in “high-risk” patients attending for review. Confirmation of the arrhythmia through an electrocardiogram (ECG) is essential.

Further investigation and clinical assessment

Further assessment and investigation focuses on identifying the cause of atrial fibrillation, on judging whether electrical or pharmacological intervention is required to control the arrhythmia and, finally, on establishing the risk of stroke and thromboembolism. Much of clinical assessment, basic blood tests (including thyroid function tests) and a chest x ray can be initiated in primary care. More specialised investigations, such as echocardiography or electrophysiological studies, may require referral to secondary care. Some general practitioners have access to open-access echocardiography, which may facilitate patient assessment for structural and functional heart disease. While most cardiologists would perform echocardiography, the guideline offers some pragmatic recommendations on when transthoracic (and transoesophageal) echocardiography should be done.

Treatment strategy

In all cases of atrial fibrillation, consideration should be given to whether the arrhythmia should be treated and how. A rhythm control …

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