a common phone call

Generally, people present with atrial fibrillation in one of three ways.

There are people who, when they develop atrial fibrillation and their symptoms manifest for the first time, go straight to hospital because the experience is new and it’s scary.

There are others in whom the atrial fibrillation is found incidentally. For these people, there is generally not a sense of urgency as they feel well. Their situation needs to be addressed promptly so that the risk of stroke is reduced, and the heart rate is then evaluated and treated so it is well-controlled.

So, ‘the phone call’ I often receive represents the group in the middle.

People often walk into their local practice saying that they haven’t been well for a few days. Maybe they have felt palpitations. Medically, they are relatively stable; they have not had a loss of consciousness; they have not had chest pain.

Such a scenario often elicits a telephone call from a general practitioner to me. The doctor wants to know whether or not this patient should be sent to accident and emergency immediately to have the possibility of atrial fibrillation treated. I always ask for a copy of the ECG to be sent through to me so that I can confirm the diagnosis, as occasionally, the problem may be an irregular pulse for reasons other than atrial fibrillation.

My feeling is that if the patient is relatively stable and in reasonable health without any other associations that would raise concerns, we can manage this patient without an urgent visit to accident and emergency. It is relatively easy to find out about renal function, thyroid function and other co-morbidities.
 
I discuss with the doctor the important actions to be taken: reduce the risk of stroke and slow the heart rate. To slow the heart rate, I recommend digoxin therapy which can be given orally, and beta blockade, generally metoprolol, which also can be given orally. To address anticoagulation, the patient can start on a NOAC which will be simple to use, can be easily acquired with a script and its usage does not require monitoring.

I then suggest to the GP that I will follow up with that patient in the next week or two after we’ve had the chance to do some important testing.

Particularly, I want to see the structure of the person’s heart, using an echocardiogram.

I’ll also make the point to the GP to tell the patient that should things not settle down, or should there be any trouble at all, to present immediately to accident and emergency.

If we are able to get some heart regulation started, together with some anticoagulation, generally we can stabilise this patient. Testing is done so that when I see this patient I have more information. Sometimes, we can even revert the patient to normal rhythm simply by these measures. And importantly, when I see the patient in my rooms, if there is the decision for direct current cardioreversion, we are almost halfway through the three to four weeks of anticoagulation needed before attempting such a procedure.

For a reasonable number of patients, we can be methodical, institute appropriate therapy, avoid an unnecessary presentation to accident and emergency, and effectively and efficiently manage the patient with available medications that can be given orally, gaining an excellent result for all concerned.