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Atrial Fibrillation (AF) statistics:
The assessment and management of adults presenting with AF
For more information please refer to the joint formulary guidance on Atrial Fibrillation (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:
HAS-BLED table:
Letter | Clinical Characteristic | Points Awarded |
H | Hypertension | 1 |
A | Abnormal renal and liver function (1 point each) | 1 or 2 |
S | Stroke | 1 |
B | Bleeding | 1 |
L | Labile INRs | 1 |
E | Elderly | 1 |
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)
Risk Factor | Points |
Congestive heart failure/LV dysfunction | +1 |
Hypertension | +1 |
Age older than 75 years | +2 |
Diabetes mellitus | +1 |
Stroke/TIA/thromboembolism | +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
Warfarin reduces:
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.
Rate control is the treatment of choice for the majority, based on the clinical judgement for the individual.
Rhythm control (minority) may be indicated if:
Echocardiogram is not routinely required if a decision to anticoagulate has already been made on clinical grounds.
For more information please refer to the joint formulary guidance on Atrial Fibrillation (AF)
Referral is not routinely required
Refer if:
Referrals may be returned if the criteria are not evident in the referral letter.
e-Referral Service Selection
British Heart Foundation Heart Health Atrial Fibrillation information
Atrial Fibrillation Association
This guideline has been signed off on behalf of NHS Devon
Publication date: December 2015