Quick Guide to Conducting an Atrial Fibrillation and Medication Review in General Practice

Overview

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with significant morbidity and mortality risks, particularly due to stroke, thromboembolism and heart failure. Managing AF effectively involves regular reviews and careful management of medication. In this guide we provide an overview of conducting a successful AF and medication review, incorporating the calculation and significance of CHA2DS2-VASc and ORBIT scores.

From a QOF 2024-25 perspective, two indicators carry a significant number of points in relation to AF:

• AF006 – % pts who have had stroke risk assessment with CHA2DS2VASc score (12 points in 2024-25)
• AF008 – % pts with CHA2DS2VASc score ≥2 on DOAC or Vit K antagonist (12 points in 2024-25)

The remaining AF QOF indicator AF001, is income-protected but only worth 5 points. You can get a quick overview of QOF 2024-25 indicators here.

Note

We have chosen not to give detailed information on anticoagulants because AskShilpa.com has some excellent information on the individual drugs that we think is very useful background reading. We have, however, included information on the ORBIT bleeding risk score because of a change in emphasis at NICE since 2021, when HAS-BLED was generally more popular.

1. Preparation

Patient Records:

• Review the patient’s medical history, previous AF episodes, and recent test results.
• Ensure access to the patient’s ECG records, blood test results, and any imaging studies.

Checklist:

• Prepare a checklist to cover all necessary aspects of the review, including risk assessments and medication evaluations.

2. Initial Consultation

Greeting and Rapport:

• Start with a warm greeting to put the patient at ease.

Purpose Explanation:

• Explain the purpose of the review and outline what will be covered.

3. Medical History Review

Current Symptoms:

• Ask about recent symptoms such as palpitations, dizziness, shortness of breath, chest pain, and any episodes of syncope.

AF Episodes:

• Document the frequency, duration, and severity of AF episodes.

Lifestyle Factors:

• Discuss lifestyle factors that might affect AF, including alcohol consumption, caffeine intake, and stress levels.

Previous Interventions:

• Review the effectiveness and outcomes of previous treatments, including cardioversion, ablation, or medication adjustments.

4. Risk Assessment: CHA2DS2-VASc Score

The CHA2DS2-VASc score assesses the risk of stroke in patients with AF. Each factor is assigned a point value:

• C – Congestive heart failure or left ventricular dysfunction (1 point)
• H – Hypertension (1 point)
• A2 – Age ≥ 75 years (2 points)
• D – Diabetes mellitus (1 point)
• S2 – Prior Stroke, TIA, or thromboembolism (2 points)
• V – Vascular disease (1 point)
• A – Age 65-74 years (1 point)
• Sc – Sex category (female) (1 point)

Score Interpretation:

• 0: Low risk (consider no anticoagulation)
• 1: Intermediate risk (consider anticoagulation based on patient characteristics and preferences)
• 2 or more: High risk (recommend anticoagulation)

5. Risk Assessment: ORBIT Score

The ORBIT score helps predict the risk of major bleeding in patients on anticoagulation therapy.

Factors include:

• O – Older age ≥ 74 years (1 point)
• R – Reduced hemoglobin/hematocrit or history of anemia (2 points)
• B – Bleeding history (2 points)
• I – Insufficient kidney function (2 points)
• T – Treatment with antiplatelet therapy (1 point)

Score Interpretation:

• 0-2: Low risk of bleeding
• 3: Intermediate risk of bleeding
• 4-7: High risk of bleeding

6. Medication Review

Current Medications:

• List all medications the patient is currently taking, including dosages and frequency.

Anticoagulation Therapy:

• Assess the need for anticoagulation based on symptoms, CHA2DS2-VASc and ORBIT scores.
• If the patient is not already on anticoagulation, and this is indicated, discuss options such as warfarin, direct oral anticoagulants (DOACs), and their respective pros and cons. You may find the information on AskShilpa.com very useful for this stage of the discussion.

Rate vs. Rhythm Control:

• Evaluate the effectiveness of current rate or rhythm control medications.
• Where the patient has not yet attended secondary care for initiation on relevant treatment, offer a discussion of options such as beta-blockers or calcium channel blockers for rate control.
• For rhythm control, discuss or review medications such as amiodarone, flecainide, or sotalol.
• It is useful to make use of patient-friendly resources such as this British Heart Foundation page.

Adherence:

• Assess medication adherence and address any barriers, such as side effects or difficulty in obtaining medications.

Drug Interactions, Side Effects, Dose Adjustments and Monitoring:

• Check for potential drug interactions and side effects.
• Consider dose adjustments if necessary. Note that for DOACs, you need to use creatinine clearance and not eGFR. Your PMR software (EMIS or SystmOne) will generally flag up any mismatch between the current prescribed dose and the expected dose based on CrCl and indication; but you need to understand the basis for this. Pay particular attention to the boundaries for dose adjustments as renal function declines. This will vary among the DOACs.
• Consider seeking specialist input at extremes of weight.
• Monitoring frequency will depend on factors such as the Creatinine Clearance, age, frailty and local protocols. This might mean that the frequency at times does not match NICE guidelines. For instance, while NICE recommends a frequency of CrCl/10 for values less than 60 ml/min, EMIS and some local protocols recommend a six monthly review if the values are between approximately 40 and 60 ml/min.

7. Lifestyle and Comorbidities Management

Weight and Exercise:

• Discuss weight management and encourage regular physical activity.

Diet and Alcohol:

• Advise on a heart-healthy diet and moderate alcohol consumption.

Smoking Cessation:

• Offer support and resources for smoking cessation if applicable.

Comorbid Conditions:

• Manage comorbid conditions such as hypertension, diabetes, and heart failure.

8. Patient Education and Self-Management

Symptom Monitoring:

• Educate the patient on recognizing and monitoring symptoms of AF.

Medication Management:

• Provide information on how to manage medications, including what to do if a dose is missed.

Emergency Plan:

• Develop an emergency plan for severe symptoms or complications.

Support Resources:

• Offer information on local support groups, educational programs, and online resources.

9. Action Plan

Goals:

• Set realistic and measurable goals for the patient to work towards before the next review.

Follow-Up:

• Schedule the next appointment and any necessary tests or referrals.

Documentation:

• Document all findings, decisions, and plans in the patient’s medical record.

10. Patient Engagement and Communication

Patient Involvement:

• Involve the patient in decision-making and encourage them to ask questions. Remember the principles of shared decision-making and effective consultation skills as per your training.

Clear Communication:

• Ensure that all explanations and instructions are clear and understandable.

Feedback:

• Ask for feedback on the review process to improve future consultations.

Conclusion

As you might have noticed above, the requirements for AF under the indicators AF006 and AF008 are relatively simple, just calculating CHA2DS2VASc and ensuring that this with a score of 2 or more are on appropriate anticoagulation. However, in this guide we have focused on providing a thorough and patient-centred approach, ultimately improving patient outcomes and quality of life. Regular reviews, clear communication, and personalised care plans are key components of successful AF management.

Other Resources

You can read more on anticoagulation from the NICE CKS. If you are a visual learner and would prefer a video explanation, we are particularly stoked by the following Ninja Nerds video, although we agree that there are lots of other good ones on YouTube.

We do, however, caution and the recognition that the drugs we use in the UK may be different from those used in other countries.

If you have found this guide useful, why not check out some of our other guides here and let us know in the comments below if there is a particular topic that you, as a pharmacy professional working in general practice, would like us to cover.