Atrial fibrillation: management

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Contents not included in this summary

 

Diagnosis and assessment

• Perform manual pulse palpation to assess for the presence of an irregular pulse that may indicate underlying atrial fibrillation in people presenting with any of the following:
  • breathlessness/dyspnoea
  • palpitations
  • syncope/dizziness
  • chest discomfort
  • stroke/transient ischaemic attack
• Perform an electrocardiogram (ECG) in all people, whether symptomatic or not, in whom atrial fibrillation is suspected because an irregular pulse has been detected
• In people with suspected paroxysmal atrial fibrillation^[A] undetected by standard ECG recording:
  • use a 24-hour ambulatory ECG monitor in those with suspected asymptomatic episodes or symptomatic episodes less than 24 hours apart
  • use an event recorder ECG in those with symptomatic episodes more than 24 hours apart

Personalised package of care and information

• Offer people with atrial fibrillation a personalised package of care. Ensure that the package of care is documented and delivered, and that it covers:
  • stroke awareness and measures to prevent stroke
  • rate control
  • assessment of symptoms for rhythm control
  • who to contact for advice if needed
  • psychological support if needed
  • up-to-date and comprehensive education and information on:
    • cause, effects and possible complications of atrial fibrillation
    • management of rate and rhythm control
    • anticoagulation
    • practical advice on anticoagulation in line with recommendation 1.3.1 in ‘Venous thromboembolic diseases’ (NICE clinical guideline 144)
    • support networks (for example, cardiovascular charities)
• NICE has produced guidance on the components of good patient experience in adult NHS services. Follow the recommendations in patient experience in adult NHS services (NICE clinical guideline 138)

Referral for specialised management

• Refer people promptly^[B] at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed

Assessment of stroke and bleeding risks

Stroke risk

• Use the CHA₂ DS₂ -VASc stroke risk score to assess stroke risk in people with any of the following:
  • symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
  • atrial flutter
  • a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm

Bleeding risk

• Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation. Offer modification and monitoring of the following risk factors:
  • uncontrolled hypertension
  • poor control of international normalised ratio (INR) (‘labile INRs’)
  • concurrent medication, for example concomitant use of aspirin or a non-steroidal anti-inflammatory drug (NSAID)
  • harmful alcohol consumption
• When discussing the benefits and risks of anticoagulation, explain to the person 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 the person is at risk of having a fall

Interventions to prevent stroke

• Do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA₂ DS₂ -VASc score of 0 for men or 1 for women)

Anticoagulation

• Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban, or a vitamin K antagonist
• Consider anticoagulation for men with a CHA₂ DS₂ -VASc score of 1. Take the bleeding risk into account
• Offer anticoagulation to people with a CHA₂ DS₂ -VASc score of 2 or above, taking bleeding risk into account
• Discuss the options for anticoagulation with the person and base the choice on their clinical features and preferences 

Apixaban

• Apixaban is recommended as an option for preventing stroke and systemic embolism within its marketing authorisation, that is, in people with nonvalvular atrial fibrillation with 1 or more risk factors such as:
  • prior stroke or transient ischaemic attack
  • age 75 years or older 
  • hypertension 
  • diabetes mellitus 
  • symptomatic heart failure 
    [This recommendation is from Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation (NICE technology appraisal guidance 275)].
• The decision about whether to start treatment with apixaban should be made after an informed discussion between the clinician and the person about the risks and benefits of apixaban compared with warfarin, dabigatran etexilate, and rivaroxaban. For people who are taking warfarin, the potential risks and benefits of switching to apixaban should be considered in light of their level of INR control
  [This recommendation is from Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation (NICE technology appraisal guidance 275)].

Dabigatran etexilate

• Dabigatran etexilate is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with nonvalvular atrial fibrillation with one or more of the following risk factors:
  • previous stroke, transient ischaemic attack, or systemic embolism
  • left ventricular ejection fraction below 40%
  • symptomatic heart failure of New York Heart Association (NYHA) class 2 or above
  • age 75 years or older 
  • age 65 years or older with one of the following: diabetes mellitus, coronary artery disease, or hypertension
    [This recommendation is from Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal guidance 249).]
• The decision about whether to start treatment with dabigatran etexilate should be made after an informed discussion between the clinician and the person about the risks and benefits of dabigatran etexilate compared with warfarin. For people who are taking warfarin, the potential risks and benefits of switching to dabigatran etexilate should be considered in light of their level of INR control
  [This recommendation is from Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal guidance 249).]

Rivaroxaban

• Rivaroxaban is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with nonvalvular atrial fibrillation with one or more risk factors such as:
  • congestive heart failure
  • hypertension
  • age 75 years or older
  • diabetes mellitus
  • prior stroke or transient ischaemic attack
    [This recommendation is from Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (NICE technology appraisal guidance 256).]
• The decision about whether to start treatment with rivaroxaban should be made after an informed discussion between the clinician and the person about the risks and benefits of rivaroxaban compared with warfarin. For people who are taking warfarin, the potential risks and benefits of switching to rivaroxaban should be considered in light of their level of INR control.
  [This recommendation is from Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (NICE technology appraisal guidance 256).

Assessing anticoagulation control with vitamin K antagonists

• Calculate the person’s time in therapeutic range (TTR) at each visit. When calculating TTR:
  • use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing
  • 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 with poor anticoagulation control shown by any of the following:
  • 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months 
  • 2 INR values less than 1.5 within the past 6 months
  • TTR less than 65%
• When reassessing anticoagulation, take into account and if possible address the following factors that may contribute to poor anticoagulation control:
  • cognitive function
  • adherence to prescribed therapy
  • illness
  • interacting drug therapy
  • lifestyle factors including diet and alcohol consumption
• If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person

Self-monitoring and self-management of vitamin K antagonists

• NICE has developed diagnostics guidance on Self-monitoring coagulation status in people on long-term vitamin K antagonist therapy who have atrial fibrillation or heart valve disease: point-of care coagulometers (the CoaguChek XS system and the INRatio2 PT/INR monitor)

Antiplatelets

• Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation

Review of people with atrial fibrillation

• For people who are not taking an anticoagulant, review stroke risk when they reach age 65 or if they develop any of the following at any age:
  • diabetes
  • heart failure
  • peripheral arterial disease
  • coronary heart disease
  • stroke, transient ischaemic attack or systemic thromboembolism
• For people who are not taking an anticoagulant because of bleeding risk or other factors, review stroke and bleeding risks annually, and ensure that all reviews and decisions are documented
• For people who are taking an anticoagulant, 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

Rate and rhythm control

When to offer rate or rhythm control

• Offer rate control as the first-line strategy to people with atrial fibrillation, except in people:
  • whose atrial fibrillation has a reversible cause
  • who have heart failure thought to be primarily caused by atrial fibrillation
  • with new-onset atrial fibrillation
  • with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
  • for whom a rhythm control strategy would be more suitable based on clinical judgement

Rate control

• Offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker as initial monotherapy to people with atrial fibrillation who need drug treatment as part of a rate control strategy. Base the choice of drug on the person’s symptoms, heart rate, comorbidities and preferences when considering drug treatment
• Consider digoxin monotherapy for people with non-paroxysmal atrial fibrillation only if they are sedentary (do no or very little physical exercise)
• If monotherapy does not control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider combination therapy with any 2 of the following:
  • a beta-blocker
  • diltiazem
  • digoxin
• Do not offer amiodarone for long-term rate control

Rhythm control

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

^[A] Paroxysmal atrial fibrillation spontaneously terminates within 7 days, usually within 48 hours.

^[B] The Guideline Development Group defined ‘promptly’ as no longer than 4 weeks after the final failed treatment or no longer than 4 weeks after recurrence of atrial fibrillation following cardioversion when further specialised management is needed.