Atrial Fibrillation (AF)

General screening for Atrial Fibrillation (AF) is not recommended. Screening is recommended for some patients with high risk conditions such as heart failure.

Screening At Annual Reviews 

The CDRC Core Data Template includes a pulse check entry. This will ensure that people with LTCs are screened for AF. 

Screening During Influenza Reviews 

The Influenza Vaccination Template includes some quick action buttons to record pulse rhythm. 

Additional Screening 

CDRC can be configured to show alerts to prompt clinicians to screen for AF. 

A Patient Status Alert (PSA) is available that displays the following icon to the right of the CDRC GMS icon: 

Clicking on the link opens the Core Data Template to allow pulse rhythm to be recorded. 

This PSA is currently built on a specification from Durham County Council: 

• Over 75y 
• Not of AF register 
• Not on CHD, CKD3-5, diabetes, heart failure, stroke/TIA registers 
• No pulse check in the last 50 months 

This specification could be altered or customised for local areas if needed 

The PSA is currently enabled for all practices in North Durham and DDES CCGs. 

 

Several reports are available to identify patients who may have undiagnosed or un-coded atrial fibrillation/flutter. 

One particularly useful strategy is to set these reports to run in a batch process (Automated Reporting) to go your cardiovascular/AF lead at regular intervals (6 to 12 monthly is a reasonable frequency). 

A spreadsheet is available to support the drug to diagnosis audits Drug to Diagnosis Spreadsheet – Cardiac

These reports are in the folder CDRC Quality > Cardiovascular 

Report Name	Returns	Notes
? AF 2.1 Casefinding – Medication that might be for AF but no AF code	Patients on rate limiting calcium channel blockers, beta-blockers, digoxin or amiodarone without obvious coded indication for these drugs.	Also likely to detect patients with other uncoded diagnoses such as hypertension and heart failure  NB – the drug to diagnosis searches below find the same patients and are easier to use.
? AF 2.2 Casefinding – AF potential indicator but no AF code	Patients with Read codes suggestive of AF but no QoF code e.g. H/O Atrial fibrillation.	Use the QoF CDRC Template (AF page – Non QoF AF Codes panel) to identify the relevant codes.
? AF 2.3 Casefinding – Irregular pulse but no subsequent ECG	Patients who have an irregular pulse without a subsequent ECG.	Some of these patients will have erroneous entries of irregular pulse.
? AF 2.4 Casefinding – AF marked as resolved	Patients who have previously had AF which is currently marked as resolved.	AF resolved should not be used for patients with paroxysmal AF who are not currently in AF.
? Drug to Diagnosis 002 – Antiarrhythmics without obvious indication		Also likely to detect other diagnoses such as heart failure, SVT, VT.
? Drug to Diagnosis 004 – Betablocker without obvious indication		Also likely to detect other diagnoses such as hypertension, heart failure, SVT, CHD.
? Drug to Diagnosis 005 – Calcium channel blocker without obvious indication		Also likely to detect other diagnoses such as hypertension, Raynauds, SVT, CHD.
? Drug to Diagnosis 008 – Anticoagulants without obvious indication		Also likely to detect other diagnoses such as VTE, mechanical heart valves.

The following searches are available to help improve the care of patients with atrial fibrillation.  One particularly useful strategy is to set these reports to run in a batch process (Automated Reporting) to go your cardiovascular/AF lead at regular intervals (1-2 monthly is a reasonable frequency). 

These reports are in the folder CDRC Quality > Cardiovascular 

Report Name	Returns	Action
? AF 3.1 Case management – AF without CHADSVASc or possibly incorrect score	Patients with AF who do not have a CHADSVASc score or whose most recently recorded score may be incorrect.	Review patient and add/update score if appropriate.
? AF 3.2 Case management – Consider Anticoagulation	Patients with AF and moderate or high stroke risk who are not anticoagulated and do have an expiring exception in the last year or a persistent exception.	Review the patient and consider anticoagulation or record exception if appropriate.

The AF Dashboard provides an overview of AF management at a particular unit or group of units. 

These reports are in the folder CDRC Performance > Cardiovascular 

The following elements of the CDRC AF system will help with QoF performance. 

Use the searches highlighted in the ‘Detecting un-coded AF’ node above – this is because QoF payments are linked to prevalence so payments are higher if prevalence is higher.

These QoF reports are located in the folder CDRC Contracting > QoF

AF006 – CHADSVASc score recorded in the last 12m (low/moderate risk patients) 

Report Name	Action	Notes
AF006 CHA2DS2-VASc in last 12m 1.2 EOY Not Achieved	The CHADSVASc score can be added quickly from the AF template	Ideally add this to a batch report for the beginning of Q3

AF008 – Anticoagulation in the last 6m for patients with AF and CHADSVASc >=2 

The following reports will identify patients to review to improve this indicator. 

Report Name	Action	Notes
AF008 CHA2DS2-VASc >2 + anticoagulated 1.11 EOY – WORK TO DO – Update CHADSVASc to achieve	The CHADSVASc score can be added quickly from the AF template	Simple addition of the CHADSVASc score will mean the patient achieves this indicator
AF008 CHA2DS2-VASc >2 + anticoagulated 1.113 EOY – WORK TO DO – Possible undiagnosed high risk AF – on anticoagulants	Review the record to see if AF diagnosis has been missed / miscoded. These patients are already on anticoagulation	e.g. has code for ECG: Atrial fibrillation but no QoF AF code. The coding tab of the AF template will help to show non-QoF codes
AF008 CHA2DS2-VASc >2 + anticoagulated 1.114 EOY – WORK TO DO – Possible undiagnosed high risk AF – not on anticoagulants	Review the record to see if AF diagnosis has been missed / miscoded then consider offering anticoagulation if AF confirmed	The coding tab of the AF template will help to show non-QoF codes
AF008 CHA2DS2-VASc >2 and anticoagulated 1.2 EOY – Excepted	Review these patients who are already excepted and consider if anticoagulation would be appropriate

Consider running the follow reports in automatic batches so the relevant professional or group are notified about patients to review at appropriate interval.  For more details on setting this up see Automated Reporting 

AF Management

Monthly Batch 

Report Name	Location	Returns	Notes
? AF 3.1 Case management – AF without CHADSVASc or possibly incorrect score	CDRC Quality > Cardiovascular	Patients whose CHADSVASc score (based on the information in the record) appears to be different from the recorded score	Use the CHADSVASc button on the AF template to record the score
? AF 3.2 Case management – Consider Anticoagulation	CDRC Quality > Cardiovascular	Patients with AF – consider anticoagulation	Review record / patient

AF Detection

Annual Batch (ideally at the beginning of Q4) 

Report Name	Location	Returns	Notes
? AF 2.1 Casefinding – Medication that might be for AF but no AF code	CDRC Quality > Cardiovascular	Patients with medications that might be for AF rate control without an obvious reason	Review record. Consider appropriate coding.
? AF 2.2 Casefinding – AF potential indicator but no AF code	CDRC Quality > Cardiovascular	Patients who are not on the AF register with a code that might suggest AF e.g. H/o atrial fibrillation	Review record using the AF coding tab of the AF template. Consider adding AF codes or marking erroneous codes in error.
? AF 2.4 Casefinding – AF marked as resolved	CDRC Quality > Cardiovascular	Patients marked as AF resolved	Review records and consider need to mark AF Resolved code in error. More information.

AF Management

Report Name	Location	Notes
AF006 CHA2DS2-VASc in last 12m 1.11 EOY – WORK TO DO	CDRC Contracting > QoF	Necessary for QoF but doesn’t help patient management  Use the AF Template to add CHADSVASc scores

The Atrial Fibrillation AF CDRC Template provides an overview of Atrial Fibrillation/Flutter management.

How to Access

In the lower left hand corner use the search bar, type in ‘Atrial Fibrillation AF CDRC’ and select the following template:

Alternatively, press F12 and search for ‘Atrial Fibrillation AF CDRC’, this will return the aforementioned template.

The Home Page will be used on most occasions. 

The top panel allows the user to provide a summary of AF management e.g. AF type, rate vs rhythm control status, who is currently involved in care, any narrative information. 

The Pulse Control panel allows recording of current pulse rate and rhythm. The right hand box will show: 

• Rate and rhythm control drugs (beta-blockers, rate limiting calcium channel blockers, digoxin, amiodarone and other antiarrhythmics such as flecainide and propafenone. 
• Previous relevant cardiovascular procedures such as cardioversions and ablations. 

The Medication Timeline button will display previous medication so it possible to see when previous treatments were started/stopped. 

The Stroke Risk panel is divided into three columns: 

• Column 1 – Links 
  • Link to CHADSVASc Calculator 
  • Link to HASBLED Calculator 
  • Link to Cardiovascular Network Guidance on anticoagulation decision making. 
  • Link to Anticoagulation template 
  • Link to information about Anticoagulation Exceptions 

• Column 2 – Current information 
  • Current CHADVASc score. An alert is displayed if the current estimated CHADSVASc score is different to the most recently recorded score 

• Current HASBLED score 
  • Current antiplatelets/anticoagulants 
    • The following information is also displayed in this box: 
    • Recent expiring exception 
    • Persistent exception 
    • Evidence of poor concordance with anticoagulation treatment 
    • Evidence of poor warfarin control 
    • Evidence that DOAC treatment might need to change e.g. dose reduction/significant interactions. 

• Column 3 – performance indicators 
  • QoF AF006 indicator – CHADSVASc recorded 
  • HASBLED 
  • QoF AF007 indicator – patients with CHADSVASc >=2 treated with anticoagulation (example below) 

CHADVASc Calculator

The CDRC system uses the system-wide TPP CHADSVASc calculator. However, there are some significant flaws in the TPP calculator (detailed below).  This CDRC link will first run checks to look for these problems and provide warnings, allowing the user to adjust the CHADSVASc score if needed. 

Potential Issues With TPP CHADSVASc Calculator 

Issue	Description	Effect	Action
Over diagnosis of hypertension	TPP calculator counts codes such as white coat hypertension and pregnancy induced hypertension as ‘currently hypertensive’	Potential overestimate	Manually reduce score if the patient is not hypertensive
Over diagnosis of diabetes	TPP calculator counts codes such as metabolic syndrome as ‘currently diabetic’	Potential overestimate	Manually reduce score if the patient is not diabetic
Underdiagnoses of heart failure, hypertension, stroke/TIA	TPP calculator does not include some codes for these conditions	Potential underestimate	Manually increase score if the patient has one of these conditions

HASBLED Calculator

Stroke vs Bleeding Risk

Anticoagulation Exceptions

This template shows anticoagulation exceptions. 

‘Expiring’ exceptions are shown in the top half and ‘persisting’ exceptions in the lower half 

The Investigations Page page shows recommendation for testing and relevant information from the record. 

The AF Referral Page page shows referral guidance.

Many patients with ‘resolved’ atrial fibrillation remain at increased risk of thromboembolic disease and should often be managed as if they have AF.  The following guide for the management of people with past, transient or intermittent AF is put together by consensus of the North East and North Cumbria Cardiovascular Network. 

Paroxysmal AF	These patients usually retain a long term higher risk of stroke	Retain on the AF register and manage as AF unless instructed by a specialist – i.e. anticoagulation based on CHADsVASc vs bleeding risk assessment
AF related to hyperthyroidism	Long term risks of recurrence and thromboembolism are likely to be similar to background population	For patients whose only risk for AF is hyperthyroidism and where the AF resolves with successful treatment of the hyperthyroidism, mark the AF as resolved.  Most commonly this affects young, otherwise healthy women.
AF and cardioversion/other procedures	Patients remain at significantly higher risk of thromboembolism from AF after successful ablation/cardioversion procedures	Unless otherwise advised by a specialist, do not mark these patients as AF Resolved. They should be managed as if they have AF.
AF after cardiac surgery	Transient AF is common after cardiac surgery such as CABG	Take advice from cardiology about whether these patients should be included on the AF register.
AF due to other stresses	Transient AF is not uncommon during other stresses such as non-cardiac surgery or infection.	Take advice from cardiology about whether these patients should be included on the AF register.

The AF Template can help to record such reviews – in the Overview section 

For practices who have recently joined the DCS group on SystmOne, PSAs and Protocols will not be automatically active. You can choose the level of activation you would like; opt-in to all or resource specific CDRC resource PSAs and Protocols. Alternatively you can choose not to opt-in and only use the Reports and Templates.

If you would like to activate that following, or all, CDRC PSAs and Protocols, please email contact-cdrc@ahsn-nenc.org.uk

The AF Bundle of opt-in resources includes: 

Patient Status Alert:

This PSA highlights whether the patient has AF.

Protocols:

Protocol Title	Trigger	Action
AF Casefinding – Irregular Pulse AUTO S	Open patient with last pulse check irregular without subsequent ECG	Prompts user to check pulse rhythm +/- ECG
AF Casefinding – AF Potential Ind Added AUTO S	Triggers when a non-QoF potential AF indicator is added to a patient without AF (e.g. ECG:AF)	Prompts the user to consider coding AF
AF Casefinding – AF Potential Proc Added AUTO S	Triggers when a cardiac arrhythmia procedure is added to a patient without an obvious reason	Prompts the user to consider adding appropriate codes