Guidance
2 Clinical need and practice
2 Clinical need and practice
The problem addressed
2.1 Lead-I electrocardiogram (ECG) devices can be used in primary care to help detect atrial fibrillation in people presenting with signs or symptoms of the condition, who have an irregular pulse on manual pulse palpation. The devices include electrodes, internal storage for ECG recordings and automated software to interpret the ECG trace. Data can be transferred to a local or remote computer for further analysis by a healthcare professional.
2.2 Using lead-I ECG devices may improve detection of atrial fibrillation. This would lead to earlier identification of people who are at a higher risk of having a stroke and who would benefit from anticoagulant treatment. Using lead‑I ECG devices would also allow ECGs to be quickly recorded when atrial fibrillation is suspected. This may help identify people with intermittent (paroxysmal) atrial fibrillation, which might have stopped before a 12‑lead ECG can be done. The scope of this assessment is the use of the devices for single time point testing for people presenting in primary care with signs or symptoms of atrial fibrillation, and an irregular pulse.
The condition
Atrial fibrillation
2.3 Atrial fibrillation is a type of arrhythmia that causes an irregular or abnormally fast heart rate. It is the most common arrhythmia and has a higher incidence in older people. When a person has atrial fibrillation the upper chambers of the heart (the atria) beat irregularly, making the heart less effective at moving blood into the ventricles. This can cause blood clots to form, which may cause a stroke. Early detection of atrial fibrillation allows preventative treatment to be started, for example, oral anticoagulants to reduce the risk of stroke.
2.4 The abnormal electrical impulses that cause the condition can result in persistent, permanent or intermittent atrial fibrillation:
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permanent atrial fibrillation: atrial fibrillation is present all the time
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persistent atrial fibrillation: episodes last longer than 7 days (if left untreated)
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paroxysmal atrial fibrillation: intermittent episodes that usually last less than 2 days and stop without treatment.
2.5 Signs and symptoms of atrial fibrillation include feeling dizzy, being short of breath, feeling tired, having chest discomfort and heart palpitations. Atrial fibrillation can also be asymptomatic.
The diagnostics and care pathways
Diagnosis
2.6 NICE's guideline on atrial fibrillation recommends that manual pulse palpation should be used to assess for an irregular pulse, which may indicate underlying atrial fibrillation in people presenting with any of the following: breathlessness (dyspnoea), palpitations, syncope (dizziness), chest discomfort, stroke or transient ischaemic attack.
2.7 The guideline also recommends doing an ECG in all people, whether symptomatic or not, when atrial fibrillation is suspected because an irregular pulse has been detected. In current practice a 12‑lead ECG can be done in primary or secondary care and is interpreted by a trained healthcare professional. This would be used to confirm atrial fibrillation that is suspected based on manual pulse palpation, before treatment is started. When atrial fibrillation has already been diagnosed, a 12‑lead ECG is important to identify any additional abnormalities, such as left ventricular hypertrophy, which need to be considered when deciding on further treatment.
2.8 After an irregular pulse is detected, if there is a delay until a 12‑lead ECG is done, paroxysmal atrial fibrillation may have stopped and therefore won't be detected by the ECG. Clinical experts advised that lead‑I ECGs would be used in the diagnostic pathway for people with signs and symptoms of atrial fibrillation after manual pulse palpation has revealed an irregular pulse.
Care pathway
2.9 NICE's guideline on atrial fibrillation makes recommendations for the care of people diagnosed with atrial fibrillation:
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Assessment of risk and treatment to lower risk of stroke: This includes assessing stroke and bleeding risk using the CHA2DS2VASc and HAS-BLED scores, and treatments to lower the risk of stroke (apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist). NICE has produced technology appraisal guidance on the direct oral anticoagulants apixaban, dabigatran etexilate and rivaroxaban and on edoxaban.
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Treatment to control heart rate and rhythm: This includes different interventions that are offered as part of a rate control strategy (beta blockers, calcium channel blocker, digoxin) or rhythm control strategy (pharmacological or electrical rhythm control or both), when appropriate.
The guideline also covers the use of left atrial ablation if drug treatment has failed to control atrial fibrillation symptoms or is unsuitable.