Atrial Fibrillation Clinic - Heart Health

The goal of this provincial initiative is to improve access to care for patients living with this rhythm disorder. Nurse and Pharmacist Clinicians use a telephone-based service (virtual presence), and specialized cardiologists (located at Pulse Complete Cardiac Care) facilitate both telephone and in-person visits, that aim to provide education and medical management strategies to improve the quality of life for people experiencing atrial fibrillation (AF) and/or atrial flutter (AFL). 

Read the AFC Mission Statement.

We do this through:

• consultation with a heart specialist doctor (cardiologist) and registered nurse or pharmacist, to establish a safe and individualized treatment plan
• ordering tests or procedures
• telephone follow-up to help plan care and treatment
• counselling and information about atrial fibrillation and medications
• referrals to other programs and services as required

Who can participate?

People experiencing atrial fibrillation and/or atrial flutter, who reside on Vancouver Island or surrounding communities. Our education videos are available for anyone who is interested to learn more about atrial fibrillation and atrial flutter.

Patients awaiting consultation from one of our clinic cardiologists are required to watch the first two sections to ensure they are well informed for their visit.

Learn about atrial fibrillation and atrial flutter – required viewing for AFC patients

Please watch this education video about atrial fibrillation (AF) and atrial flutter (AFL) before attending any clinician appointments for AF/AFL management.

Living well with atrial fibrillation –  required viewing for AFC patients

 Learn about lifestyle interventions you can make to slow the progression of atrial fibrillation (AF).

Patients awaiting consultation from one of our clinic cardiologists are required to watch the video below to ensure they are well informed for their visit.

See the modifiable risk factors for atrial fibrillation.

Management options for modifiable risk factors:

Image from: Canadian Journal of Cardiology 2020 361847-1948DOI: (10.1016/j.cjca.2020.09.001).

Learn more about:

• alcohol effects on your health
• healthy eating with diabetes
• sleep apnea
• monitoring your home blood pressure

Download this helpful home blood pressure log.

Learn more about the importance of exercise in managing AF from the video below:

Managing anxiety associated with atrial fibrillation

Anxiety and stress can be a symptom of atrial arrhythmia as well as a possible acute trigger for atrial fibrillation.

In addition to support from your primary care provider, the following self-help resources may aid you to further reduce anxiety and stress:

• Bounce Back 
• MindShift CBT (cognitive behavioral therapy) app 
• Anxiety Canada 
• Positive coping with health conditions workbook 

Medications for Stroke Prevention

We recommend that you watch the general education videos in the above sections of this page first as the following medication videos will refer to medical terms and discuss concepts that were explained in the prior videos.

Stroke caused by atrial fibrillation (AF) is highly preventable when treated appropriately with anticoagulants.

DOACs, or “Direct-acting Oral Anti-Coagulants, are often recommended first line when anticoagulation is indicated in AF.

Four DOACs are currently approved for use in Canada: apixaban, dabigatran, edoxaban, and rivaroxaban. Learn more in this video:

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Warfarin may be considered for anticoagulation in cases where DOACs cannot be used; for example, in AF patients with mechanical heart valves or rheumatic valve disease.

Learn more in the following video:

 

Medications for Rate Control

Rate control ensures that the heart does not beat too quickly with atrial fibrillation (AF).
Medications can be used to slow a fast heart rate, thereby lessening symptoms as well as the risks for certain other heart-related complications.
Examples include:

• Beta Blockers (like bisoprolol, metoprolol or carvedilol)
• certain Calcium Channel Blockers (diltiazem or verapamil)
• Digoxin, in some cases

  Note: common beta blockers include: metoprolol, bisoprolol & carvedilol
   

  Note: common calcium channel blockers include: diltiazem & verapamil

Medications for Rhythm Control

Rhythm control means trying to get the heart back to a normal rhythm and then help keep it there. Medications known as anti-arrhythmic agents are one way to re-establish a normal rhythm.

These medications are not for everyone and should first be prescribed by an appropriate specialist (e.g. internist or cardiologist).

We recommend that you first view the introductory education found in the above section of this page (learn about atrial fibrillation and atrial flutter – required viewing for AFC patients) as the following videos use medical terminology and build upon concepts discussed in that section.

 

Learn About Cardioversion and Ablation Procedures

Cardioversion – English, Farsi, Traditional Chinese, Simplified Chinese, or Punjabi
Ablation for atrial fibrillation – English, Farsi, Traditional Chinese, Simplified Chinese, or Punjabi
Ablation for atrial flutter – English, Farsi, Traditional Chinese, Simplified Chinese, or Punjabi
Ablation for atrioventricular node – English, Farsi, Traditional Chinese, Simplified Chinese, or Punjabi
Pacemaker – English, Farsi, Traditional Chinese, Simplified Chinese, or Punjabi
Recovering for ablation for atrial fibrillation – English

Information for Referring Physicians

Referral to the AFC may not be necessary if:

• only a single episode of AF/AFL & risk-factors and comorbidities well-managed
• infrequent paroxysmal AF/AFL, with no/minimal symptoms, appropriate antithrombotic therapy & good rate/rhythm control 
• persistent AF/AFL, with no/minimal symptoms, appropriate antithrombotic therapy, good rate control with no desire to restore sinus rhythm

If your patient has a BMI > 35, then consider a referral to a metabolic clinic as weight loss > 10% resulted in a 6 fold greater probability of arrhythmia free survival and 45.5% of such patients in the LEGACY trial no longer needed anti-arrhythmic therapy or ablation.

Site specific referrals can be downloaded for:

• Victoria Cardio-Metabolic Collaborative Clinic 
• Aroga Lifestyle Medicine Clinic 

If your patient consumes >21 alcoholic beverages per week and has not been able to abstain or minimize their use upon clinician request, then consider referral to a support program as indicated since appropriate lifestyle interventions may be sufficient for maintaining regular rhythm.

See the Rapid Access Addiction Clinic  and referral form. 

If your patient has been recently identified as having untreated hyperthyroidism, then please refer to an endocrinologist for management as this remains an important treatable cause of AF. Be aware that the Canadian Cardiovascular Society suggested in 2020 that “most patients with secondary AF due to thyrotoxicosis be anticoagulated until a euthyroid state is restored.” This is an independent risk factor for thromboembolic events regardless of CHAD-65 scoring.

When to refer to the AFC?

• complex decisions regarding rhythm-control (e.g., failed one or more antiarrhythmic drugs, consideration of AF ablation)
• recurrent typical atrial flutter (AFL) where CTI ablation may be indicated
• complex decisions regarding rate-control (e.g., pacemaker & AV node ablation when simple rate-control medications are ineffective or not tolerated)
• prior AF/AFL ablation with recurrences of dysrhythmia
• fast-track DC Cardioversion (DCCV). This option is intended for local practitioners who would like an elective DCCV arranged at the Royal Jubilee Hospital for a patient with symptomatic persistent AF/AFL. As the AFC nursing and pharmacy staff do not have prescribing privileges, it is expected that the referring physician will ensure these patients are appropriately anticoagulated and rate-controlled with confirmation via ECG/Holter in the interim. These outpatient bookings are limited and average ~8 weeks out from request. The “fast-track” refers to the expedited access to an accompanying cardiology/EP consultation pre-procedure. Patients with new signs and symptoms of heart failure (eg. orthopnea, peripheral edema, paroxysmal nocturnal dyspnea) or with highly uncontrolled ventricular rates at risk for tachycardia-mediated cardiomyopathy should be directed to Emergency Services instead.  

If your patient does not meet the AFC eligibility requirements in the referral form and you would still like your patient to receive a cardiology consultation within the South Island region, then:

• refer to the PULSE Complete Cardiac Care referral form and ensure that under the reason for referral you check the box after “If they do not meet the AFC criteria”.

If you would like to learn more about monitoring rhythm or rate control therapy while awaiting EP consultation, then please see the following CSBC algorithms:

• amiodarone
• beta blockers
• calcium channel blockers
• digoxin
• dronedarone
• flecainide
• propafenone
• sotalol
• or call the AFC clinical pharmacist directly at 250-370-8740