Non-Covid clinical crises: New onset atrial fibrillation
Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available
Stroke risk assessment and management, rate control, symptom control and red flags for secondary care support.
The patient record should hold enough information to calculate the CHA2DS-Vasc score and anticoagulation can be started for those at high risk. DOACs are the preferred drugs because they can be started with minimal need for face-to-face contact so long as a recent creatinine level and weight is known.
In established AF, anticoagulated with warfarin, it may be appropriate to switch to a DOAC and there is national guidance now available. The patient with non-valvular AF can be switched to a DOAC when the INR is < 2.5. GPs are asked to switch in the 12-week monitoring cycle to avoid compromise to the supply of these drugs. Guidance can be found on the pccsuk.org ‘COVID19 learning bites’.
One phlebotomy appointment for FBC CUE LFT & TFT may be needed. Rate control may be relaxed to avoid the risk of bradycardia or pauses and locally we aim for 100bpm in clinic. Bisoprolol starting 2.5-5mg is our drug of choice. If patients have asthma or COPD that is too unstable for even a cardio-selective beta-blocker then diltiazem starting for example at 120mg XL OD is an option. Consider loop diuretics if symptoms or signs of heart failure.
Utilise patient home data from BP machines and wearables where possible. Red flags would include significant angina, uncontrolled heart failure, syncope, or AF with Wolff-Parkinson-White. In these cases, even in lockdown, secondary care support should be sought and may require admission.
Other less urgent treatment may be considered, if appropriate, once COVID restrictions are relaxed. Referral for outpatient echocardiography and ambulatory ECG recording may still be required, particularly if the patient remains symptomatic despite apparent adequate rate control.
Dr Richard Blakey is a GPwSI in cardiology in Sussex