CHAPTER 12

The appropriate management of the atrial fibrillation (AF) patient requires a collaboration between the primary care physician and the cardiologist. Decisions made about patient care are shared, with specific responsibility assumed by the primary care physician or cardiologist. In some settings, the primary care doctor will assume the majority of decision making whereas in others it will be the cardiologist. Increasingly, nurse practitioners are assuming more responsibility for clinical care in both primary care and cardiology. Although the focus of this chapter is on the multidisciplinary approach between the primary care physician and the cardiologist, it is evident that patient management for AF often includes nurse practitioners. In this respect, references to the primary care physician and cardiologists are made inclusive of all the healthcare professional team members who provide care to the AF patient. The current chapter discusses the management of the AF patient with respect to the roles and responsibilities of primary care and cardiology healthcare provider teams, with an emphasis on the physician’s role. The role of the nurse practitioner is further discussed in Chapter 13.

ROLE OF THE PRIMARY CARE PHYSICIAN IN THE INITIAL MANAGEMENT OF AF

Although AF may be detected during an emergency room visit prompted by severe symptoms (dyspnea, angina, dizziness/hypotension), it will commonly be detected first by the primary care physician after investigation of mild symptoms (palpitations, sensation of rapid heartbeat, reduced exercise tolerance) or on routine examination when an irregular pulse is noted.1,2 Occult AF may also be detected after outpatient electrocardiographic monitoring following cerebrovascular accident of unclear cause.³

The initial decision is whether outpatient management is appropriate or whether the patient needs urgent transfer to an emergency room or hospital setting for immediate rate control or electrical cardioversion. Evidence of ischemia, heart failure, hemodynamic instability (particularly with evidence of organ hypoperfusion), or very rapid heart rate (particularly in setting of preexcitation) would prompt such a transfer.

If such an urgent transfer is not needed, the primary care physician should initiate the search for an underlying cause. AF may result from a number of underlying conditions, both cardiac and noncardiac. AF occurs in 10% to 14% of patient with pulmonary embolism.⁴ AF is very common in the first few weeks after cardiac surgery. It does occur after noncardiac surgery, although not as frequently as after cardiac surgery, so pulmonary embolus should at least be considered when it occurs in this setting. Pneumonia may also precipitate AF. Thyroid stimulating hormone (TSH) should be checked, as hyperthyroidism is a common cause of AF. Other underlying, noncardiac medical conditions associated with AF include diabetes, obesity, chronic kidney disease, pericarditis, hypertension, and possibly sleep apnea. After the diagnosis and initial treatment of AF, the primary care physician needs to decide the need for, and urgency of, consultation with a cardiologist.⁴

ROLE OF THE PRIMARY CARE PHYSICIAN AND CARDIOLOGIST IN THE SUBSEQUENT MANAGEMENT OF AF

If it has been determined that outpatient management is appropriate, the next decisions are whether rate control is necessary in the short run, whether anticoagulation is indicated, and whether rate or rhythm control is the preferred approach for long-term management. If urgent cardioversion is not indicated, in principle these initial decisions can be made by the primary care physician without consultation with a cardiologist. Optimally, of course, these decisions are made as part of a process of shared decision making with the patient.^5,6 The potential risks of AF include arterial embolism and the side effects of anticoagulation and antiarrhythmic drugs. These must be communicated as clearly as possible to the patient, so that they can integrate their preferences, including risk preferences, with the clinical data. Whether the primary care physician feels comfortable/competent doing this without consultation depends, of course, on his/her level of expertise, experience, and familiarity with the relevant medical literature. If the patient is referred to a cardiologist, the initial role of the primary care physician is to provide the cardiologist the clinical data relevant to making these decisions. The primary care physician therefore needs to be aware of the clinical factors that influence the decision. Optimally, though, the process will be a collaborative one with an in-depth discussion ensuing between the primary care physician and the cardiologist after the initial consultation. Because a large part of these decisions involves incorporating patient preferences into the risk/benefit equation on the basis of medical literature, the primary care physician who typically knows that patient best may be in a better position to engage the patient in this type of discussion.

The decision who should be anticoagulated has generally been according to CHADS₂ or CHA₂DS₂-VASc scores (Tables 12.1 and 12.2), with the latest guidelines giving preference to the latter.^6–8 The CHA₂DS₂-VASc score gives an estimate of annual stroke risk based on clinical characteristics including age (1 point for > 65 years, 2 for > 75 years), hypertension (1 point), diabetes (1 point), heart failure (1 point), previous stroke (2 ponts), vascular disease (1 point), and female gender (1 point). In the latest AF guidelines, a CHA₂DS₂-VASc of 2 generally warrants anticoagulation.⁶ The decision to use anticoagulants must be based on weighing the risk against the benefits, so bleeding risk must also be considered. Commonly, patients with significant bleeding risks were excluded from trials that demonstrated net benefit from anticoagulants. There are a number of risk scores designed to predict bleeding risk, though it is not clear how predictive these scores are.^9,10 The hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly (HAS-BLED) is probably the most accurate (Tables 12.3 and 12.4).¹⁰ Other factors that may be harder to assess include compliance (both with medication and with diet where that is relevant) and fall risk. Until recently, warfarin was the only drug available for oral anticoagulation, but several other drugs are now available. These novel agents have several benefits, including lack of need for blood monitoring and freedom from dietary restrictions, and are increasingly recommended for the treatment of nonvalvular AF.⁶ The choice of drug will be influenced by several factors, including need for monitoring with warfarin, compliance issues (with twice daily dosing needed with some drugs, increased risk of clot with cessation of some drugs), kidney function, age, and cost. Anticoagulation rates in practice are relatively low. Most studies show that we are using too little anticoagulation in our patients with AF.¹¹

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