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Designing atrial fibrillation services

Map of Medicine has analysed the evidence on how best to design atrial fibrillation services, and suggested interventions to achieve specific productivity improvements while maintaining quality and safety.

1Use a pill-in-pocket (PIP) strategy to treat selected patients with paroxysmal atrial fibrillation (AF).1

NICE guidance recommends using a PIP strategy in patients with paroxysmal

AF provided they have a systolic blood pressure over 100mmHg, a resting heart rate above 70bpm, no history of valvular or ischaemic heart disease, and the ability to recognise when to take their medication.1

The PIP approach may be used in selected, highly symptomatic patients with infrequent (between once per month and once per year) recurrences of AF.2

A health technology assessment compared three different management strategies for paroxysmal AF and found they all had equal clinical effectiveness.

PIP was shown to be the most cost-effective option with a mean cost of treatment of £1,512, compared with £2,389 for continuous antiarrhythmic drugs and £2,340 for in-hospital treatment.3


2Use a rate control strategy as the first-line treatment in selected patients with persistent AF.1

NICE guidance recommends that rate control strategy should be used as first-line treatment in patients aged over 65 years with persistent AF who are known to have coronary artery disease, but not congestive cardiac failure, and who are not suitable candidates for cardioversion.1

There is no significant difference in mortality rates, thromboembolic events or major bleeding events between rate and rhythm control strategies.4

A US economic evaluation concluded that rate control was, on average, US$5,077 (approximately £2,800) cheaper per person than rhythm control at US$20,546 (approximately £11,500) versus US$25,6235 – the higher costs being attributed to electrical cardioversion (ECV), hospital admissions or antiarrhythmic medications.6


3Use pharmacological cardioversion (PCV) as the initial treatment strategy in patients presenting with haemodynamically stable AF of recent onset (within 48 hours).1,7

A US economic evaluation concluded that initial treatment with PCV, followed by ECV if sinus rhythm was not restored, was more likely to result in successful cardioversion in those patients than where the treatment order was reversed (96% versus 84% respectively).7 The same study observed that the mean cost of PCV was US$1,240 (approximately £700) per patient versus US$1,917 (approximately £1,100) with the electrical method.7


4Place all patients with AF at risk of stroke on anticoagulation therapy.1

NHS Improvement estimates there are up to 40% of patients with AF who could benefit from anticoagulation therapy not receiving it.8 The cost per stroke due to AF is estimated to be £11,900 in the first year. Maintaining a patient on warfarin for a year, including monitoring, costs £383.8

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The productivity considerations presented in this document are relevant to the UK. They were identified by systematically searching for and appraising productivity evidence from multiple sources, including NICE guidance, health economic databases and Zynx Health (a sister company of Map of Medicine). A productivity message explicitly states interventions that can reduce the cost of care, while maintaining or improving patient outcomes. Actions that are believed to lead to improved productivity, but lack unequivocal clinical or economic evidence, are not included. Some productivity considerations are informed by more recent evidence than that included in relevant national guidelines. The document has been peer reviewed by an independent group of experts.

© 2011 Map of Medicine Ltd Atrial fibrillation 1/2


1. The National Collaborating Centre for chronic conditions (NCCC).

Atrial Fibrillation. National Clinical Guideline for management in

primary and secondary care. London: Royal College of Physicians;


2. European Heart Rhythm Association; European Association for

Cardio-Thoracic Surgery. Guidelines for the management of atrial

fibrillation: the Task Force for the Management of Atrial Fibrillation

of the European Society of Cardiology (ESC). Eur Heart J 2010; 31:


3. Martin Saborido C, Hockenhull J, Bagust A et al. Systematic review

and cost-effectiveness evaluation of ‘pill-in-the pocket' strategy

for paroxysmal atrial fibrillation compared to episodic in-hospital

treatment or continuous antiarrhythmic drug therapy. Health

Technol Assess 2010; 14: 1-104.

4. Opolski G, Torbicki A, Kosior D et al. Rhythm control versus rate

control in patients with persistent atrial fibrillation. Results of the

HOT CAFE Polish Study. Kardiol Pol 2003; 59: 1-16.

5. Marshall D, Levy A, Vidaillet H et al. Cost-effectiveness of rhythm

versus rate control in atrial fibrillation. Ann Intern Med 2004; 141:


6. Hagens V, Vermeulen K, TenVergert E et al. Rate control is more

cost-effective than rhythm control for patients with persistent

atrial fibrillation – results from the RAte Control versus Electrical

cardioversion (RACE) study. Eur Heart J 2004; 25: 1542-9.

7. de Paola A, Figueiredo E, Sesso R et al. Effectiveness and costs

of chemical versus electrical cardioversion of atrial fibrillation. Int J

Cardiol 2003; 88: 157-66.

8. Tyndall K. The Guidance on Risk Assessment and Stroke

Prevention in Atrial Fibrillation. London: NHS Improvement; 2009