Atrial Fibrillation

For the purpose of this assignment I have chosen to review a client with atrial fibrillation in a primary care setting. I will discuss the patient's original presentation, including

analysis and interpretation of his 12 lead electrocardiogram (ECG), diagnosis and subsequent management. Throughout the assignment I will discuss local and national guidelines and the evidence behind the chosen management for this client. For the purpose of this assignment the client will be referred to as Mr. Jones.

Cardiac arrhythmias affect more than 700,000 people in England is one of the top ten reasons for hospital admission (Department of Health 2005). Atrial fibrillation (AF) is the most common and important cardiac arrhythmia, it the most common of all the arrhythmias seen in general practice. AF affects 5% of the UK population over the age of 65 years, rising to 10% in those over 75 years of age (Kirby 2005). The principal significance, both to the patient and the healthcare system is the increased risk of embolic stroke. Atrial fibrillation is associated with 15% of all strokes and with 36% of strokes in patients over the age of 60 (Hobbs 1999). Having a diagnosis of AF increases the risk of stroke five fold. It is an arrhythmia associated with serious morbidity, mortality and health service utilisation. AF and its complications now consume 1% of the United Kingdom National Health Service budget (Watson, Shanstila, and Lip 2007). Despite this it is an area that frequently remains unrecognised in general practices.

Within primary care AF is an area that has not been fully addressed. However the introduction of the National Service Frameworks and updated National Institute for Health and Clinical Excellence (NICE) guidelines has brought this condition to the forefront of primary care teams. Standard five of the National Service Framework (NSF)

Older People (DOH 2001) states that primary care teams should have had in place by April 2004 the following ' Every general practice, using protocols, agreed with local specialist services, can identify and treat patients identified at being at risk of stroke because of high blood pressure, AF or other risk factors. This statement is supported by a component of standard three of the NSF for Coronary Heart Disease (CHD) which states that 'warfarin or aspirin for people over 60 years old who also have atrial fibrillation' (DOH 2000). Despite the fact that these should have been in place by 2004 many general practices are still struggling to address the many issues surrounding correct diagnosis, identification and management of patients with AF.

Unfortunately, the condition is often unrecognised both by clinicians and patients; this could be partly due to the fact that AF can be symptom less in many people. In the Cardiovascular Health Study (1994) 12% of new AF cases were identified on the basis of a yearly ECG recording alone, presumably because these patients had no symptoms. Sudlow (1997) states that in a population based survey of patients over the age of 65 years in northern England, only 76% of patients with AF were known to their General Practitioner (GP), whilst another similar study involving ECG screening in central England found that only 31% of patients with AF were recognised (Hobbs 1998). All of these surveys are a few years old now and one would hope that as AF becomes a more highlighted area within primary care, and the benefits and importance of appropriate anti

coagulation and early cardioversion become more apparent these figures will improve dramatically. Ceresne and Upshur (2002) state that as the vast majority of care is now delivered within a primary care setting it is important to determine the number of clients who have AF and to ensure whether or not they are receiving the optimum treatment for their condition.

One of the main areas of concern in relation to the recognisation and identification of cardiac arrhythmias (especially AF) in general practice is in ensuring that the most appropriate method is used to both highlight and treat these clients. Pulse palpation is currently the most commonly used assessment within primary care but this has implications around correct technique. This should be helped by the introduction of primary prevention clinics and more training and evidence based guidelines being made available both to GP's and nurses in relation to AF. There were no studies as to what would be the most appropriate method of identification within a primary care setting

Case Study

Mr Jones, a 66 year old gentleman, was invited to his local GP's practice to attend a primary prevention screening clinic. He had no relevant past medical history and was currently taking no prescribed medication. He had a premature family history of heart disease (father died of a Myocardial Infarction aged 50 years; mother suffered a stroke aged 67 years). He was a smoker, was employed part time as a gardener, and felt that he was fairly fit. He took no regular exercise and had a body mass index of 26. At the clinic Mr Jones blood pressure was recorded at 162/85 and his pulse taken. On pulse palpation it was noticed that Mr Jones rate appeared irregular. On discussion with the client he stated that over the last six to eight months he had been feeling "an odd sensation in his chest", when questioned further he said these could be described as palpitations and were becoming more regular. He had occasional shortness of breath and was more lethargic than usual, but felt that these did not significantly affect his quality of life. After discussion with the GP an appointment for an Electrocardiogram (ECG) was arranged for the following week. Not all GP practices have the facility to record ECG's on the premises, this in turn could lead to problems around correct diagnosis and treatment within primary care, if the government guidelines and targets issued around AF in primary care are to be met there need to be adequate provision both in means of equipment, appropriately trained staff and primary care's capacity to be able to implement these. Blood tests were taken at the practice, these included full blood chemistry, haematology, coagulation profile, glucose, thyroid function tests and liver function tests. These would help to exclude any underlying causes (e.g. hyperthyroidism), assess suitability for anti-coagulation and check baseline values prior to any commencement of treatment which may involve potentially toxic drugs (e.g. amiadarone). It was felt at this time this client may have atrial fibrillation and it was necessary to confirm this diagnosis and initiate treatment if necessary.

Patients with AF will usually present with palpations and/or symptoms of an underlying cause. For patients with a persistent