Feature Article

Atrial fibrillation management. The central role of the GP

David Brieger, CIA CONNELL, CHARLOTTE HESPE, Nicholas Zwar

Figures

© lisa clark
© lisa clark

Abstract

Opportunistic annual screening for atrial fibrillation (AF) is strongly recommended in those aged 65 years and over and is easily accomplished. Integrated care to support comprehensive treatment and address the specific needs of people with AF is required, and GPs are central to its effective delivery.
Update
An updated version of Table 2 in this article is available here.

Key Points

  • Opportunistic screening for atrial fibrillation (AF) in the clinic or community is recommended for all patients aged over 65 years.
  • Deciding between a rate and rhythm control strategy at the time of diagnosis of AF and periodically thereafter is important.
  • Beta-blockers or nondihydropyridine calcium channel antagonists (e.g. diltiazem, verapamil) remain the first-line choice for acute and chronic rate control.
  • When pharmacologic rhythm control is the selected strategy, flecainide is preferable to amiodarone for both acute and chronic rhythm control provided left ventricular function is normal and patient does not have coronary disease.
  • Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation.
  • The sexless CHA2DS2-VA assessment, which standardises thresholds across men and women, is recommended to assess stroke risk.
  • Anticoagulation is recommended for a CHA2DS2-VA score of 2 or more.
  • When anticoagulation is indicated, nonvitamin K oral anticoagulants (NOACs) are recommended in preference to warfarin.
  • Net clinical benefit almost always favours stroke prevention over major bleeding, so bleeding risk scores should not be used to avoid anticoagulation in patients with AF.
  • An integrated care approach using patient education and available e-health tools and resources should be delivered by a multidisciplinary team.
  • Regular monitoring and feedback of risk-factor control helps to ensure treatment adherence and persistence.

Figures

© lisa clark
© lisa clark