High risk groups 1

  • > 65 years of age
  • Aboriginal and Torres Strait Islander people > 55 years of age
  • Those with:
    • Hypertension
    • Heart failure
    • Coronary heart disease
    • Overweight and obesity (adult)
    • Diabetes
    • Chronic kidney disease
    • valvular heart disease
    • dilated cardiomyopathy
  • Family history of atrial fibrillation (AF)

Urgent referral

  • Consult specialist if:
    • haemodynamically unstable AF may require cardioversion with sedation
    • long-term control of AF has been ineffective

1. What is AF? 1,2

  • An irregular and often rapid ventricular rate due to an unrecognised or under-treated insult that continues to damage the atrial myocardium
  • Can arise in a normal heart but usually with:
    • major structural heart valve abnormalities or
    • Heart failure, Overweight and obesity (adults) or Diabetes
  • Symptoms include palpitations, shortness of breath and fatigue, but many patients are asymptomatic
  • Symptoms can result from acute episodes of new onset AF, or from breakthrough rapid episodes in those with an established diagnosis of AF
  • The longer a person remains in AF, the greater the likelihood of developing an atrial clot or having a stroke, causing serious morbidity or death
  • Deaths from complications (i.e. heart failure) remain high, despite adherence to treatment
  • Aboriginal and Torres Strait Islander people have a higher incidence of and mortality attributed to AF

2. Diagnosis of AF 1,2

  • Opportunistic screening of high risk groups by:
    • pulse palpation, and if irregular or unsure
    • an ECG
  • Confirmed with a documented ECG rhythm episode of irregular RR intervals with no discernible P waves, lasting > 30 seconds
  • Those with pacemakers and implanted devices should be examined regularly for atrial high-rate episodes, and confirmed by an atrial ECG to be AF
  • An echocardiogram is performed in all patients with newly diagnosed AF to identify and manage:
    • valvular heart disease
    • quantifying left ventricle function
    • atrial size

Table 1. Patterns of AF 1,2

Paroxysmal

  • Episodes that:
    • self-terminate between 2–7 days
    • may recur with variable frequency

Persistent

  • Episodes that last > 7 days and do not self-terminate

Long standing persistent

  • Lasting for ≥ 1 year
  • Patient requires a rhythm control strategy

Permanent

  • Clinical and personal acceptance of irreversible AF rather than attributed to pathophysiology
  • No further attempts to restore or maintain sinus rhythm

3. Management of AF 1,2

  • The goals of managing AF are to:
    • reduce risk of thromboembolism and stroke
    • relieve symptoms
    • aggressively identify and manage comorbidities, specifically:
      • Hypertension
      • Heart failure
      • Coronary heart disease
      • valvular heart disease
      • Overweight and obesity (adult)
      • Diabetes
      • Chronic kidney disease
      • Alcohol reduction
      • hyperthyroidism
  1. Support patient self-management 1
    • See Lifestyle modifications
    • Discuss what AF is and how it progresses
    • Provide AF Resources 1–5.
    • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients.

Table 2. Target goals to manage AF 1

Weight loss

  • At least 10% weight loss or BMI < 27 kg/m2

Exercise

  • 210 minutes of wkly aerobic exercise

Blood pressure

  • ≤ 130/80 mm Hg

Sleep apnoea

  • CPAP therapy
  • See Physical activity and sleep

Diabetes

  • HbA1c ≤ 6.5%

Lipids

  • See Dyslipidaemia

Smoking cessation

  • See Smoking cessation

Alcohol consumption

  • See Alcohol reduction
  1. Social-emotional support
    • See Social-emotional wellbeing
  2. Physical activity 1
    • Physical activity strengthens the atrial myocardium and reduces progression of AF
    • Exercise that improves aerobic capacity is recommended in individuals with symptomatic AF to reduce the AF burden
    • See Physical activity and sleep
  3. Weight reduction 1–3
    • Being overweight places increased demand on the heart which increases the risk of developing AF
    • The greater the weight loss, the more likely sinus rhythm is maintained
    • Overweight and obese patients should begin an intensive weight management program targeting:
      • a ≥ 10% loss of body weight or
      • a final BMI < 27 kg/m2
    • These targets have shown marked:
      • reductions in AF symptom burden, episode frequency and duration
      • improvements in quality of life
    • See Overweight and obesity (adult)
  4. Smoking cessation 1–3
    • Smoking is a risk factor for all comorbidities linked to AF
    • Encourage patients to quit smoking. See Smoking cessation
  5. Alcohol reduction
    • Excessive alcohol consumption is a risk factor for developing and progressing AF
    • See Alcohol reduction
  6. Obstructive sleep apnoea (OSA) 1–3
    • Sleep apnoea sustains and worsens AF
    • There is a strong relationship between obesity and OSA, both conditions being
      common in patients with AF
    • Addressing sleep apnoea improves sinus rhythm with rhythm-control strategies
    • Manage by:
      • weight reduction. See Overweight and obesity (adult), page 366, Diet and nutrition and Physical activity and sleep,avoiding CNS depressants e.g. opiates, alcohol
      • CPAP therapy
    • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 6.

2. Medicines for AF 2

  • Initiation of medicines to treat AF is done by, or in consultation with, a cardiologist
    1. Prevention of thromoembolic events 1,2,3,6
      • All patients with AF should be considered for antithrombotic therapy
      • The choice of antithrombotic medicine is determined by those with moderate-severe mitral stenosis or mechanical heart valve (valvular-AF) and those without (non-valvular AF) . See Flowchart 1.

Flowchart 1. Antithrombotic therapy for patients with AF

Antithrombotic therapy for patients with AF

Table 3. Anticoagulant therapy for patients with AF 1–4

Warfarin

  • Only for those with valvular AF

See Safe use of warfarin for detailed use and education

Direct oral anticoagulants (DOACs)

  • For those with non-valvular AF. Lack of evidence for valvular AF. May be harmful
  • Have a predictable dose response and do not need routine anticoagulation monitoring
  • Follow dosage recommendations exactly. Underdosing may not prevent thromboembolism or stroke
  • Absolute contraindications to DOAC include active serious bleeding (identify and treat), comorbidities (e.g. severe thrombocytopenia < 50 platelets/lL, severe anaemia under investigation), or a recent high-risk bleeding event such as intracranial haemorrhage (ICH)

Dabigatran

  • < 75 years age and CrCl > 50 mL/min then 150 mg PO bd
  • < 75 years age and CrCl 30–50 mL/min, or risk of major bleeding then 110 mg PO bd
  • ≥ 75 years and CrCl > 30 mL/min then 110 mg PO bd
  • Avoid if CrCl < 30 mL/min

Rivaroxaban

  • CrCl ≥ 50 mL/min then 20 mg PO, once a day
  • CrCl ≥ 15 to 49 mL/min then 15 mg PO, once a day
  • Avoid if CrCl < 15 mL/min

Apixaban (non-LAM)

  • 5 mg PO bd OR
  • If ≥ 2 bleeding risk factors then 2.5 mg PO bd
  • Avoid if CrCl < 25 mL/min
  1. Rate-control strategy 1–3
    • Attempts to improve haemodynamic status, reduce symptoms and control heart rate using medicines
    • For symptomatic and asymptomatic patients irrespective of LV function
    • Aim for resting HR < 90 bpm
    • Usually relies on oral medicines, IV is rarely necessary
    • Choice of medicine will depend on absence or presence of LV dysfunction. See Table 4. for long-term rate-control medicines
  2. Rhythm-control strategy1–3
    • Attempts to reduce symptoms and restore and maintain sinus rhythm using medicines (cardioversion)
    • Is for patients who are symptomatic or have left ventricular dysfunction that might be secondary to AF
    • Should be avoided if a person has been in AF > 48 hours until they have been fully anticoagulated
    • Should be weighed against adverse effects, and the patient’s symptoms and preference
    • See Table 5. for long-term rhythm-control medicines
    • Select, document and communicate a rate-control or rhythm-control strategy with the patient and review regularly

Table 4. Long-term rate-control of AF 1–4

Beta blockers

  • To attain and maintain long-term control of ventricular HR

Atenolol 25 mg PO, daily (to max. 100 mg daily)

Metoprolol25 mg PO, bd (to max. 100 mg bd)

Calcium channel blockers

  • If beta blockers are not tolerated or contraindicated
  • To attain and maintain long-term control of ventricular HR
  • Avoid in patients with left ventricular dysfunction

Verapamil MR180 mg PO, daily (to a max. 480 mg bd)

Diltiazem MR 180 mg PO, daily (to max. 360 mg daily)

Amiodarone

  • For those with left ventricular dysfunction, or if above medicines not effective
  • Used as an add-on to other medicines
  • LAM restricted. Must be prescribed by cardiologist before use

Amiodarone 200 mg PO, daily

Digoxin

  • May be considered as add-on therapy to above medicines or if above are contraindicated
  • Monitor 5 days after starting or changing dose, then 6 mthly. Adjust to 2 wkly for those with renal impairment
  • Aim for levels of 0.5–0.8 microgs/L. Avoid levels > 1.2 microg/L

Digoxin 62.5 to 250 microgs PO, daily, according to age, body weight and CrCl

For those with AF whose rate is not adequately controlled by medicines, seek specialist cardiology advice

Table 5. Long-term rhythm-control of AF (continued)1–4

Table 5. Long-term rhythm-control of AF 1–4

Flecanide

  • To maintain sinus rhythm in those who have normal LV function and no coronary disease
  • Use in combination with a beta blocker (i.e. metoprolol or atenolol) or calcium channel blocker (i.e. diltiazem or verapamil) to decrease the risk of conversion to atrial flutter
  • Contraindicated in heart block, second or third-degree or bifascicular block (without pacemaker), or abnormal ejection fraction or LVH more than 14 mm

Flecainide50 mg PO, bd (to a max. 150 mg bd)

Sotalol

  • Monitor for QT prolongation
  • Cease if QT or QTc interval exceeds 500 milliseconds or increases > 20% from baseline
  • Use low doses initially
  • Avoid in renal impairment
  • Caution with left ventricular dysfunction

Sotalol40 mg PO, bd (to a max. 160 mg bd)

Amiodarone

  • For those where above medicines not effective
  • LAM restricted. Must be prescribed by cardiologist before use

Amiodarone 200 mg PO, tds for 1 week, then bd for 1 week, then once a day

For those with AF who do not respond to antiarrhythmic medicine therapy, seek specialist cardiology advice

5. Cycle of care

Cycle of care summary for AF

Action

Dx

Review frequency

Height

Once only

BMI

6 mthly

Weight

Daily for 2 wks then as clinically required

Waist circumference

3 mthly

Pulse rate and rhythm

Each time medicines supplied or patient visits clinic

Blood pressure

Each time medicines supplied or patient visits clinic

Urinalysis

12 mthly

Fasting blood glucose

12 mthly

Echocardiogram

If significant change in clinical condition otherwise every 2 yrs

Coagulant levels

As per anti-coagulant requirement

Digoxin levels

5 days after starting or changing dose then 6 mthly. Adjust to 2 wkly for those with renal impairment

ECG

12 mthly

Social-emotional wellbeing

Each visit

Lifestyle modification

Each visit

Self management education

Each visit

Influenza, pneumococcal and COVID-19 vaccines

Recommended. See the Australian Immunisation Handbookfor schedule

Dietitian

3 mthly

Rate-control strategy

Each visit

Rhythm-control strategy

Each visit

MO/NP review

3–6 mthly

RN/IHW review

3 mthly

Cardiologist

6–12 mthly as per specialist recommendations

6. References

7. Resources

  1. National Heart Foundation atrial fibrillation information
  2. Heart Support Australia
  3. Cardiomyopathy Association of Australia
  4. Heart Foundation support
  5. Heartonline education and toolkits
  6. The Epworth Sleepiness Scale and STOP-Bang questionnaire

Last updated: September 2024

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