NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE General practice Indicators for the NICE menu Indicator area: Pulse rhythm assessment for AF Indicator: NM146 Date: June 2017 Introduction There is evidence to suggest that a significant proportion of people with atrial fibrillation (AF) are undiagnosed and therefore not receiving appropriate treatment to prevent the risk of stroke and other complications, associated with AF. Pulse rhythm assessment, represents a low resource method for identifying the presence of an irregular pulse. Additionally, pulse rhythm assessment should be performed prior to undertaking a blood pressure recording. Indicator: NM146: The percentage of patients registered at the practice aged 65 years and over who have been diagnosed with one or more of the following conditions: coronary heart disease, heart failure, hypertension, diabetes, CKD, PAD, or stroke/tia who have had a pulse rhythm assessment in the preceding 12 months. Source guidance and recommendations Hypertension in adults NICE clinical guideline CG127 (2011) Recommendation 1.1.2: Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. 1
Myocardial infarction, NICE clinical guideline CG172 (2013) Recommendation 1.3.2: Ensure that a clear management plan is available to the person who has had an MI and is also sent to the GP, including: Details and timing of any further drug titration Monitoring of blood pressure Monitoring of renal function. Chronic heart failure in adults NICE clinical guideline CG108 (2010) Recommendation 1.4.1.1: All patients with chronic heart failure require monitoring. This monitoring should include: A clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status A review of medication, including need for changes and possible side effects Serum urea, electrolytes, creatinine and egfr. Type 1 diabetes in adults, NICE clinical guideline NG17 (2015, updated 2016) Recommendation 1.13.2: Assess cardiovascular risk factors annually, including: Albuminuria Smoking Blood glucose control Blood pressure 2
Full lipid profile (including HDL and LDL cholesterol and triglycerides) Age Family history of cardiovascular disease Abdominal adiposity. Type 2 diabetes in adults NICE guideline NG28 (2015, updated 2017) Recommendation 1.4.1: Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice. Chronic kidney disease NICE Guideline CG182 (2014, updated 2015) Recommendation 1.6.1: In people with CKD aim to keep the systolic blood pressure below 140mmHg (target range 120-139 mmhg) and the diastolic blood pressure below 90 mmhg. Peripheral arterial disease NICE guideline CG147 (2012) Recommendation 1.2.1: Offer all people with peripheral arterial disease information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance (see related NICE guidance) on: Smoking cessation Diet, weight management and exercise Lipid modification and statin therapy The prevention, diagnosis and management of diabetes The prevention, diagnosis and management of high blood pressure 3
Antiplatelet therapy. Stroke and transient ischaemic attack in over 16s NICE guideline CG68 (2008, updated 2017) Recommendation 1.5.3.2: Blood pressure reduction to 185/110 mmhg or lower should be considered in people who are candidates for thrombolysis. Rationale This indicator measures the proportion of patients with one or more of the listed conditions, aged 65 years and over, who have had an assessment of pulse rhythm on at least one occasion in the preceding 12 months. NICE Guidance recommends that patients with these conditions should have their blood pressure recorded on an annual basis. Pulse rhythm should be assessed prior to taking an automated blood pressure as an irregular pulse can affect the accuracy of the blood pressure measurement. Patients with these conditions are also at increased risk of cardiac arrhythmias, including atrial fibrillation. Untreated atrial fibrillation represents a significant and potentially preventable stroke risk. Patients with an irregular pulse should be offered further investigations to identify the cause of any arrhythmia. Reporting and verification See indicator wording for requirement criteria. Pulse rhythm may be assessed using manual palpation or suitable devices such as the WatchBP Home A device. References Hypertension in adults: diagnosis and management, NICE clinical guideline CG127 (2011, updated 2016) Myocardial infarction, NICE clinical guideline CG172 (2013 Chronic heart failure in adults NICE clinical guideline CG108 (2010) 4
Type 1 diabetes in adults, NICE clinical guideline NG17 (2015, updated 2016) Type 2 diabetes in adults: management, NICE clinical guideline NG28 (2015, updated 2017) Chronic kidney disease in adults: assessment and management, NICE clinical guideline CG182 (2014, updated 2015) Peripheral arterial disease: diagnosis and management, NICE guideline CG147 (2012) Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, NICE guideline CG68 (2008, updated 2017) WatchBP Home A for opportunistically detecting atrial fibrillation during diagnosis and monitoring of hypertension, Medical technologies guidance MTG13 (2013) 5