Timeframe: from diagnosis until effective therapy of atrial fibrillation (AF)

Setting: outpatient setting, inpatient setting, emergency department

Including:

investigation and assessment of underlying causes

stroke prevention

drug therapy for acute and long-term heart rate or heart rhythm control, cardioversion

integrated care

Excluding: performing ablations [atrial or atrioventricular (AV) node] or ‘left atrial appendage occlusions’ (specialist management)

• Medical expert

• Communicator

• Collaborator

• Leader

• Professional

• Outline the epidemiology, pathophysiology, and prognosis of AF

• Classify AF according to its causes, severity, and temporal pattern

• Recognize the clinical and electrocardiographic features of AF including pre-excited AF

• Discuss the importance of co-existing structural heart diseases on the prognosis and implications for the management of AF

• Describe how diagnostic procedures should be tailored to the individual circumstances

• List the risk factors for stroke and bleeding

• Describe the indications, contraindications, side effects, and complications of:

  •   – Anticoagulant therapy

  •   – Rhythm vs. rate control therapy

  •   – Pharmacological control of ventricular rate

  •   – Anti-arrhythmic drug therapy

  •   – Pharmacological cardioversion

  •   – Electrical cardioversion

  •   – Pacemaker therapy

  •   – Catheter ablation of AF

  •   – Surgical ablation of AF

  •   – Surgical or interventional occlusion of the left atrial appendage

  •   – Catheter ablation of the AV node

• Discuss combined, staged, or hybrid approaches in patients with AF and structural heart disease

• Take a relevant history and perform an appropriate physical examination

• Assess quality of life using the European Heart Rhythm Association score

• Analyse the ECG and monitoring devices to diagnose AF and differentiate it from other rhythm disorders

• Use validated scores to assess the risks of thromboembolism and bleeding

• Select the best strategy for prevention of ischaemic stroke and systemic embolism

• Treat reversible bleeding risk factors

• Implement appropriate treatment:

  •   – Anticoagulant therapy and, where necessary for other indications, combination with antiplatelet therapy

  •   – Switch from one anticoagulant drug to another

  •   – Rate control vs. rate plus rhythm control

  •   – Anti-arrhythmic drug therapy

  •   – Pharmacological cardioversion

  •   – Pharmacological control of ventricular rate

  •   – Electrical cardioversion

• Manage predisposing and associated conditions and co-morbidities

• Educate the patient with AF how to reduce the rate of relapse by lifestyle modifications such as exercise and weight loss

• Identify patients for referral for interventional procedures: catheter or AV node ablation; left atrial appendage occlusion

• Collaborate with the multi-disciplinary AF team

• Recognize the impact on a patient’s quality of life from symptoms and anxiety over anticoagulant therapy and invasive methods of management

• Emphasize the over-riding importance of anticoagulant therapy for most patients

• Explain the limitations and risks of anti-arrhythmic drug therapy

• Help patients to understand the success rate, limitations, and risks of AF ablation

• Acknowledge the importance of information and education to patients and carers

• Promote shared and integrated care: team working with patients, general practitioners, nurses, electrophysiologists, surgeons, haematologists, and other healthcare providers

• Direct observation/WBA (e.g. DOPS, Mini-CEX, fieldnotes)

• CbD (case-based discussion)/EbD (entrustment-based discussion)

• 5. Able to teach (no supervision)