AF commonly occurs in association with risk factors, such as heart disease, diabetes, hypertension and hyperthyroidism. Opportunistic assessment for the presence of AF may be prudent in patients with these risk factors, especially since these patients are frequently seen for check-ups in primary care.

Perform manual pulse palpation to assess for the presence of an irregular pulse if there is a suspicion of AF. This includes people presenting with any of the following:

• breathlessness/dyspnoea
• palpitations
• syncope/dizziness
• chest discomfort
• stroke/transient ischaemic attack

Perform a 12-lead ECG to make a diagnosis of AF if an irregular pulse is detected in people with suspected AF with or without symptoms. A single lead ECG should not be used to confirm a diagnosis of AF.

• In people with suspected paroxysmal AF undetected by 12-lead ECG recording:
  use a 24-hour ambulatory ECG monitor if symptomatic episodes are less than 24 hours apart or if there is a concern about asymptomatic episodes, for example in a patient presenting with a stroke or TIA.
• use an ambulatory ECG monitor, event recorder or other ECG technology for a period appropriate to detect AF if symptomatic episodes are more than 24 hours apart.

Patients with a confirmed diagnosis of AF

NICE suggest select patients are referred for echocardiography, see:

• Direct access echocardiogram: East Devon / North Devon

Clinical Referral Guidance for atrial fibrillation, see: 

• East Devon / North Devon

If heart rate causing haemodynamic compromise (low BP, heart failure, chest pain, dizziness, syncope), then refer for immediate hospital admission.

A rate control strategy accepts the presence or occurrence of AF and aims to control ventricular rate and degree of irregularity despite continuing fibrillation within the atria. The alternative strategy of rhythm control attempts to restore and maintain sinus rhythm.

Refer people promptly at any stage if treatment fails to control the symptoms of AF and more specialised management is needed.

Offer rate control as the first-line strategy to all people with AF, except people:

• with AF which has a reversible cause
• with heart failure thought to be primarily caused by AF
• with new-onset AF
• with atrial flutter whose condition is suitable for ablation surgery
• for whom rhythm control strategy would be more suitable

Adequate control is indicated by a resting heart rate of less than 80/min and a maximum heart rate on exercise of 200/min-age, or when an individualised target heart rate leaves a patient asymptomatic. 

Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences when considering drug treatment.

Treatment options

Initial monotherapy

Offer one of the following options (unless the person does no or very little exercise or these options are not suitable due to comorbidities or patient preference):

• a beta-blocker (other than sotalol) 
  • For people with concomitant heart failure, follow the recommendations on the use of beta-blockers in Chronic heart failure
  • Sotalol should not be used for rate control due to risk of pro-arrhythmia
  • See Beta-adrenoreceptor blocking drugs

OR

• a rate-limiting calcium-channel blocker (diltiazem [off-label] or verapamil) 
  • Avoid in chronic heart failure
  • Verapamil should not be combined with a beta-blocker (including eye drops) due to the adverse effects on left ventricular function. The combination of diltiazem with beta-blockers should be used with caution.
  • See Calcium-channel blockers

Consider digoxin monotherapy for non-paroxysmal AF if:

• the person does no or very little physical exercise, or
• other rate-limiting drug options are ruled out because of comorbidities or the person's preference
• See Positive inotropic drugs

Digoxin is less effective for rate control during exercise or in conditions of high sympathetic drive (for example: infection or decompensated heart failure).

Combination therapy

If monotherapy does not control symptoms (thought due to poor ventricular rate control), consider combination therapy with any 2 of the following:

• a beta-blocker (other than sotalol)
• diltiazem (off-label)
• digoxin

Amiodarone

Do not offer amiodarone for long-term rate control.

Consider pharmacological and/or electrical rhythm control for people with AF whose symptoms continue after heart rate has been controlled or a rate-control strategy has not been successful.

Cardioversion

For AF that has persisted for longer than 48 hours, offer electrical rather than pharmacological cardioversion.

Consider amiodarone therapy starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm.

Prior to cardioversion anticoagulation must be considered.

Long term rhythm control

Assess the need for drug treatment for long-term rhythm control, taking into account the person's preferences, associated comorbidities, risks of treatment and likelihood of recurrence of AF.

If drug treatment is needed:

• offer a beta-blocker (other than sotalol) as first-line treatment unless there are contraindications (see Beta-adrenoreceptor blocking drugs)
• If beta-blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control (see Anti-arrhythmic drugs).
  • Dronedarone is recommended as an option for the maintenance of sinus rhythm after successful cardioversion in certain patients.
  • Amiodarone may be considered for patients with left ventricular impairment or heart failure.
  • 'no drug treatment' strategy or 'pill-in-the-pocket' strategy (see below)
  • Class 1c antiarrhythmic drugs such as flecainide or propafenone should not be offered to people with ischaemic or structural heart disease.

'no drug treatment' strategy or 'pill-in-the-pocket' strategy

Where people have infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants (such as alcohol, caffeine), a 'no drug treatment' strategy or a 'pill-in-the-pocket' strategy should be considered. This should be offered following specialist assessment and the first such cardioversion should be supervised in secondary care.

Ablation is reserved for consideration in patients in whom drug treatment has failed to control symptoms of AF, or is unsuitable or not tolerated.

AF increases the risk of stroke and thromboembolism by five-fold, but this risk is not homogeneous, and is dependent upon the presence of various stroke risk factors.

Assessment of stroke risk

Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:

• symptomatic or asymptomatic paroxysmal, persistent or permanent AF
• atrial flutter
• a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm or catheter ablation

For an on-line calculator (MD+CALC), click here: CHA2DS2-VASc score for atrial fibrillation stroke risk

Assessment of bleeding risk

Assess the risk of bleeding using the ORBIT bleeding risk score when:

• considering starting anticoagulation, and
• reviewing people already taking anticoagulation

For an on-line calculator (MD+CALC), click here: ORBIT bleeding risk score

Offer modification and monitoring of the following risk factors:

• uncontrolled hypertension
• poor control of INR
• concurrent medication, including antiplatelets, selective serotonin reuptake inhibitors (SSRIs) and NSAIDs
• harmful alcohol consumption
• reversible causes of anaemia

Risk versus benefit of anticoagulation

• Discuss the benefits and risks of anticoagulation with the patient, that:
  • For most people the benefit of anticoagulation outweighs the bleeding risk.
  • For people with an increased risk of bleeding, the benefit of anticoagulation may not always outweigh the bleeding risk, and careful monitoring of bleeding risk is important.
• Do not withhold anticoagulation solely because of the person's age or their risk of falls
  
• Do not offer stroke prevention therapy with anticoagulation to people aged under 65 years with AF and no risk factors other than their sex (that is, very low risk of stroke equating to CHA2DS2-VASC score of 0 for men or 1 for women)
• Taking ORBIT score into consideration:
  
  • Consider anticoagulation with a DOAC for men with a CHA2DS2-VASc score of 1
  • Offer anticoagulation with a DOAC to people with a CHA2DS2-VASc score ≥ 2

Review of patients not receiving anticoagulation

For people not taking an anticoagulant, stroke risk should be reviewed when the patient reaches 65 years of age or if any of the following develop at any age:

• Diabetes
• Heart failure
• Peripheral arterial disease
• Coronary heart disease
• Stroke, TIA or systemic thromboembolism

For people who are not taking an anticoagulant because of bleeding risk or other factors, review stroke and bleeding risks annually

See the previous section for guidance on assessment of stroke risk (CHA2DS2-VASc) and bleeding risk (ORBIT), and other factors to consider in deciding whether anticoagulation is appropriate for a patient.

NICE guidance NG196 recommendation, taking into account risk of bleeding:

• Consider anticoagulation with a DOAC for men with a CHA2DS2-VASc score of 1
• Offer anticoagulation with a DOAC to people with a CHA2DS2-VASc score of 2 and above

Selection of a DOAC

It is for the prescribing clinician to determine which DOAC(s) are clinically appropriate for an individual patient. See section 2.8.2 Oral anticoagulants for individual drugs, dosing regimens and NICE technology appraisal (TA) criteria.

NICE guidance NG196: Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with their NICE TA criteria.

Commissioning recommendations for national procurement for DOACs (January 2024):

• For patients commencing treatment for AF: subject to the criteria specified in the relevant NICE technology appraisal guidance, clinicians should use the best value DOAC that is clinically appropriate for the patient.
• If the highest ranked best value DOAC (generic apixaban, twice a day treatment) is contraindicated or not clinically appropriate for the specific patient then, subject to the criteria specified in the relevant NICE technology appraisal guidance, clinicians should then consider edoxaban where this is clinically appropriate (see edoxaban entry note 1b), then rivaroxaban, then dabigatran, then branded apixaban (Eliquis) until an appropriate treatment is identified.

Deciding between anticoagulation treatment options

Discuss the risks and benefits of different drugs with the person.

See Anticoagulation prescribing guidance for advice on:

• Patients who should not be considered for a DOAC
• Guidance on DOAC prescribing including renal function and baseline checks
• DOAC counselling checklist

Take into account any contraindications for each drug and follow the guidance in the British National Formulary and the MHRA advice on direct-acting oral anticoagulants, in particular for advice on dosages in people with renal impairment, reversal agents and monitoring (MHRA June 2020; MHRA May 2023).

If treatment with a DOAC is not appropriate

If DOACs are contraindicated, not tolerated or not suitable, offer a vitamin K antagonist.

If anticoagulation is contraindicated or not tolerated, it may be appropriate to seek advice from a specialist.

Assessing anticoagulation control with vitamin K antagonists

Calculate the person's time in therapeutic range (TTR) at each visit. When calculating TTR:

• exclude measurements taken during the first 6 weeks of treatment
• calculate TTR over a maintenance period of at least 6 months.

Reassess anticoagulation for a person whose anticoagulation is poorly controlled shown by any of the following:

• two INR values higher than 5 or one INR value higher than 8 within the past 6 months
• two INR values less than 1.5 within the past 6 months
• TTR less than 65%

If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person

Switching from warfarin to a DOAC

For adults with atrial fibrillation who are already taking a vitamin K antagonist and are stable, continue with their current medication and discuss the option of switching treatment at their next routine appointment, taking into account the person's time in therapeutic range.

A pragmatic approach to stopping warfarin and switching to a DOAC can be found here (NHSE Management of anticoagulation services during the pandemic), weblink also included under Anticoagulation prescribing guidance.

Antiplatelets

Do not offer aspirin monotherapy solely for stroke prevention to people with AF.

For guidance on antiplatelet therapy for people who have had a myocardial infarction and are having anticoagulation, see Antiplatelet therapy for people with an ongoing separate indication for anticoagulation in NICE guidance for acute coronary syndrome (NG185).

Review of patients receiving anticoagulants

Review the need for anticoagulation and the quality of anticoagulation at least annually, or more frequently if clinically relevant events occur affecting anticoagulation or bleeding risk.

For monitoring during treatment with a DOAC, see Anticoagulation prescribing guidance.

Take into account MHRA advice on DOACs and bleeding risk and the need to monitor renal function in patients with renal impairment (MHRA June 2020; MHRA May 2023).

Stopping anticoagulation

Do not stop anticoagulation solely because AF is no longer detectable.

Base decisions to stop anticoagulation on a reassessment of stroke and bleeding risk using CHA2DS2-VASc and ORBIT and a discussion of the person's preferences.