This page was printed from the Northern & Eastern Devon Formulary and Referral site at
Please ensure you are using the current version of this document
Atrial Fibrillation (AF) statistics:
The assessment and management of adults presenting with AF
Please note pre-referral criteria may be applied to referrals for this condition.
To see information required please see Referral Section, referrals submitted without this information may be returned.
Key referral criteria summary:
Consider the causes of AF:
Look for AF by opportunistic case finding
Take the pulse in those with:
An irregular pulse has a good sensitivity and specificity especially in patients over 75 years old and if regular, the chance of AF is very small – negative predictive value around 99%
AF may also be detected as an incidental finding on clinical examination
Acute admission is indicated if:
Perform or refer for electrocardiography (ECG)
When the ECG confirms AF or flutter:
NICE Guidance CG 180-Patient decision aid - medicines to help reduce your risk of a stroke –what are the options?
Stroke prevention/ bleeding risk assessment:
|Letter||Clinical Characteristic||Points Awarded|
|A||Abnormal renal and liver function (1 point each)||1 or 2|
|D||Drugs or alcohol (1 point each)||1 or 2|
|Maximum possible score is 9|
Assess stroke risk using CHA2DS2VASc (see table below) for AF (unless the cause is a rheumatic valve where the risk is 17 times higher and anticoagulation needed)
Congestive heart failure/LV dysfunction
|Age older than 75 years||+2|
|Vascular disease (MI, aortic placque, PAD||+1|
|Age 65-74 years||+1|
|Sex category (female)||+1|
|Cumulative score||Range 0-9|
Score 2 or more (men and women) offer anticoagulants; Warfarin or a DOAC taking into account bleeding risk. If indicated but contraindicated or not tolerated, left atrial appendage occlusion may be a consideration
Score 1 in men: consider anticoagulants bearing in mind bleeding risk
Score 1 in women: no antithrombotics
Score 0 in men: no antithrombotics
In the latter 2, reassess annually – do not offer aspirin as the risks outweigh the benefits
Aspirin should not be used – no benefit compared to placebo
Other or dual antiplatelet therapy should not be used – no evidence
New oral anticoagulants (DOACs) may be used instead of warfarin in patients with:
There remain concerns related to safety data in poor compliers, renal impairment, with no antidote and a higher risk of GI bleeds (though less intracranial bleeds)
Do not offer stroke prevention therapy to people aged under 65 years old with AF and no other risk factors other than their sex.
Rhythm control (minority) may be indicated if:
Echocardiogram is not routinely required if a decision to anticoagulate has already been made on clinical grounds.
Referral is not routinely required
Referrals may be returned if the criteria are not evident in the referral letter.
e-Referral Service Selection
This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG
Publication date: December 2015