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Open Access
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.

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.

Atrial fibrillation (AF) is the most common recurrent arrhythmia faced in clinical practice, and it causes substantial morbidity and mortality.1-3 In Australia, prevalent AF cases in people aged 55 years or more are projected to double over the next two decades as a result of an ageing population and improved survival from contributory diseases.4 Recent Australian data show that hospitalisations of patients with AF increased 295% over a 21-year period – a higher increase than for myocardial infarction or heart failure over the same period.5

In many patients, AF progresses from short paroxysmal episodes to more frequent and persistent attacks, and then often to permanent AF. However, progression can be mitigated by aggressive targeting of modifiable cardiovascular risk factors.6

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AF is independently associated with an increased long-term risk of stroke, heart failure and all-cause death.1-3 The risk of dying from stroke can be reduced by administration of oral anticoagulants (OACs), but all-cause mortality and deaths from complications such as heart failure remain high, despite guideline-adherent treatment.1,7 This highlights the need for a comprehensive care approach to reduce overall mortality in AF-affected patients.8

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The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand recently produced guidelines on the diagnosis and management of AF.9 These are intended to be used by practising clinicians across all disciplines caring for such patients. This review covers the sections of the guidelines that are particularly relevant to GPs.

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Figures

© lisa clark
© lisa clark
Professor Brieger is an Interventional Cardiologist and Head of Coronary Care at Concord Hospital in Sydney; and Professor of Cardiology, Faculty of Medicine, University of Sydney, Sydney, NSW. He is on the academic staff at the ANZAC Research Institute. Ms Connell is Clinical Manager at the National Heart Foundation of Australia; and Teaching Associate at Monash University, Melbourne, Vic. Associate Professor Hespe is Head, General Practice and Primary Care Research, School of Medicine, University of Notre Dame Australia, Sydney, NSW. Professor Zwar is Executive Dean, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld.