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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.
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.
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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