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Page last updated:
3 November 2023
This guidance is based on NICE NG196: Atrial fibrillation: diagnosis and management (April 2021, updated June 2021). The guidance applies to adults aged 18 years or over.
NICE technology appraisals are referenced under the relevant drug entry:
Other formulary guidance:
Clinical referral guidance:
Commissioning recommendations for national procurement for DOACs (September 2024):
The recommendations apply to adults aged 18 years or over.
Please also refer to: Anticoagulation prescribing guidance page
Patients with AF (and their carers) should be taught to recognise the signs of a stroke (the FAST test) and the action to be taken if they spot them
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:
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.
NICE suggest select patients are referred for echocardiography, see:
Clinical Referral Guidance for atrial fibrillation, see:
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:
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.
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):
OR
Consider digoxin monotherapy for non-paroxysmal AF if:
Digoxin is less effective for rate control during exercise or in conditions of high sympathetic drive (for example: infection or decompensated heart failure).
If monotherapy does not control symptoms (thought due to poor ventricular rate control), consider combination therapy with any 2 of the following:
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.
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.
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:
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.
Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:
For an on-line calculator (MD+CALC), click here: CHA2DS2-VASc score for atrial fibrillation stroke risk
Assess the risk of bleeding using the ORBIT bleeding risk score when:
For an on-line calculator (MD+CALC), click here: ORBIT bleeding risk score
Offer modification and monitoring of the following risk factors:
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:
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:
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 (September 2024):
Discuss the risks and benefits of different drugs with the person.
See Anticoagulation prescribing guidance for advice on:
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 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.
Calculate the person's time in therapeutic range (TTR) at each visit. When calculating TTR:
Reassess anticoagulation for a person whose anticoagulation is poorly controlled shown by any of the following:
If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person
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.
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 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).
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.