Atrial Fibrillation: Diagnosis and Management

Overview

This Guidelines summary on atrial fibrillation covers diagnosis; assessment of stroke risk and cardiac function; personalised care and information; referral; stroke prevention; rate and rhythm control; and stopping anticoagulation. This summary only covers areas relevant to primary care. For the complete set of recommendations, refer to the full guideline.

Reflecting on Your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Detection and Diagnosis

• Perform manual pulse palpation to assess for the presence of an irregular pulse if there is a suspicion of atrial fibrillation (AF). This includes people presenting with any of the following:
  • breathlessness
  • palpitations
  • syncope or dizziness
  • chest discomfort
  • stroke or transient ischaemic attack
• Perform a 12-lead electrocardiogram (ECG) to make a diagnosis of AF if an irregular pulse is detected in people with suspected AF with or without symptoms
• In people with suspected paroxysmal AF undetected by 12-lead ECG recording:
  • use a 24-hour ambulatory ECG monitor if asymptomatic episodes are suspected or symptomatic episodes are less than 24 hours apart
  • 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.

Assessment of Stroke and Bleeding Risks

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

See the recommendations under Review of people with atrial fibrillation in the Stroke prevention section for advice on reassessment of stroke risk.

Bleeding Risk

• Assess the risk of bleeding when:
  • considering starting anticoagulation in people with AF and
  • reviewing people already taking anticoagulation.

Use the ORBIT bleeding risk score because evidence shows that it has a higher accuracy in predicting absolute bleeding risk than other bleeding risk tools. Accurate knowledge of bleeding risk supports shared decision making and has practical benefits, for example, increasing patient confidence and willingness to accept treatment when risk is low and prompting discussion of risk reduction when risk is high. Although ORBIT is the best tool for this purpose, other bleeding risk tools may need to be used until it is embedded in clinical pathways and electronic systems.

• Offer monitoring and support to modify risk factors for bleeding, including:
  • uncontrolled hypertension (see NICE’s guideline on hypertension in adults)
  • poor control of international normalised ratio (INR) in patients on vitamin K antagonists
  • concurrent medication, including antiplatelets, selective serotonin reuptake inhibitors, and non-steroidal anti-inflammatory drugs
  • harmful alcohol consumption (see NICE’s guideline on alcohol-use disorders: diagnosis, assessment, and management of harmful drinking and alcohol dependence)
  • reversible causes of anaemia.

Discussing the Results of the Risk Assessment

• Discuss the results of the assessments of stroke and bleeding risk with the person, taking into account their specific characteristics, for example comorbidities, and their individual preferences. For further guidance, see the section on enabling patients to actively participate in their care in NICE’s guideline on patient experience in adult NHS services.

Assessment of Cardiac Function

• Perform transthoracic echocardiography (TTE) in people with AF:
  • for whom a baseline echocardiogram is important for long-term management
  • for whom a rhythm-control strategy that includes cardioversion (electrical or pharmacological) is being considered
  • in whom there is a high risk or a suspicion of underlying structural or functional heart disease (such as heart failure or heart murmur) that influences their subsequent management (for example, choice of antiarrhythmic drug)
  • in whom refinement of clinical risk stratification for antithrombotic therapy is needed (see the sections Assessment of stroke and bleeding risks, and Stroke prevention)
• Do not routinely perform TTE solely for the purpose of further stroke risk stratification in people with AF for whom the need to start anticoagulation therapy has already been agreed on appropriate clinical criteria (see the sections Assessment of stroke and bleeding risks, and Stroke prevention)
• Perform transoesophageal echocardiography (TOE) in people with AF:
  • when TTE demonstrates an abnormality (such as valvular heart disease) that warrants further specific assessment
  • in whom TTE is technically difficult and/or of questionable quality and when there is a need to exclude cardiac abnormalities
  • for whom TOE-guided cardioversion is being considered.

Personalised Package of Care and Information

• Offer people with AF 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 AF
    • management of rate and rhythm control
    • anticoagulation
    • practical advice on anticoagulation in line with the recommendations on information and support for people having anticoagulation treatment in NICE’s guideline on venous thromboembolic diseases
    • support networks (for example, cardiovascular charities)
• Follow the recommendations on shared decision making in NICE’s guideline on patient experience in adult NHS services.

Medicines Adherence and Optimisation

• To support adherence and ensure safe and effective medicines use in people with AF, follow the recommendations in NICE’s guidelines on medicines adherence and medicines optimisation.

Referral for Specialised Management

• Refer people promptly at any stage if treatment fails to control the symptoms of AF and more specialised management is needed. This should be within 4 weeks after the failed treatment or after recurrence of AF after cardioversion.

Stroke Prevention

Anticoagulation

• When discussing the benefits and risks of anticoagulation use clinical risk profiles and personal preferences to guide treatment choices. Discuss with 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
• When deciding between anticoagulation treatment options:
  • discuss the risks and benefits of different drugs with the person and follow the recommendations on shared decision making in NICE’s guideline on patient experience in adult NHS services
  • follow the recommendations on patient involvement in decisions about medicines in NICE’s guideline on medicines adherence and patient decision aids in NICE’s guideline on medicines optimisation
  • take into account any contraindications for each drug and follow the guidance in the British National Formulary and the Medicines and Healthcare products Regulatory Agency (MHRA) advice on direct-acting oral anticoagulants, in particular for advice on dosages in people with renal impairment, reversal agents and monitoring
• Offer anticoagulation with a direct-acting oral anticoagulant to people with AF and a CHA₂DS₂-VASc score of two or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban, and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (see anticoagulation treatment in the NICE pathway on preventing stroke in people with AF)
• Consider anticoagulation with a direct-acting oral anticoagulant for men with AF and a CHA₂DS₂-VASc score of one, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban, and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance
• If direct-acting oral anticoagulants are contraindicated, not tolerated, or not suitable in people with AF, offer a vitamin K antagonist. See the section on self-monitoring and self-management of vitamin K antagonists
• For adults with AF 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
• Do not offer stroke prevention therapy with anticoagulation to people aged under 65 with AF and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA₂DS₂-VASc score of zero for men or one for women)
• Do not withhold anticoagulation solely because of a person’s age or their risk of falls.

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 whose anticoagulation is poorly controlled shown by any of the following:
  • two INR values higher than five or one INR value higher than eight within the past 6 months
  • two 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 atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system).

Antiplatelets

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’s guideline on acute coronary syndromes. Do not offer aspirin monotherapy solely for stroke prevention to people with AF.

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 (taking into account MHRA advice on direct-acting oral anticoagulants about bleeding risk and the need to monitor renal function in patients with renal impairment) at least annually, or more frequently if clinically relevant events occur affecting anticoagulation or bleeding risk.

Rate and Rhythm Control

Rate Control

• Offer rate control as the first-line treatment strategy for AF except in people:
  • whose AF has a reversible cause
  • who have heart failure thought to be primarily caused by AF
  • with new-onset AF
  • 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
• Offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem^[A] or verapamil) as initial rate-control monotherapy to people with AF unless the person has the features described in the following recommendation on digoxin monotherapy. Base the choice of drug on the person’s symptoms, heart rate, comorbidities, and preferences
• For people with AF and concomitant heart failure, follow the recommendations on the use of beta-blockers and avoiding calcium-channel blockers in NICE’s guideline on chronic heart failure
• Consider digoxin monotherapy for initial rate control for people with 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 preferences
• If monotherapy does not control the person’s symptoms, and if continuing symptoms are thought to be caused by poor ventricular rate control, consider combination therapy with any two of the following:
  • a beta-blocker
  • diltiazem^[A]
  • digoxin
• Do not offer amiodarone for long-term rate control.

Rhythm Control

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

Antiarrhythmic Drug Therapy

• 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
• Do not offer class 1c antiarrhythmic drugs such as flecainide or propafenone to people with known ischaemic or structural heart disease
• If drug treatment for long-term rhythm control is needed, consider a standard beta-blocker (that is, a beta-blocker other than sotalol) as first-line treatment unless there are contraindications
• If beta-blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control, taking comorbidities into account
• Follow the advice on dronedarone as a second-line treatment option for long-term rhythm control after successful cardioversion in NICE’s technology appraisal guidance on dronedarone for the treatment of non-permanent AF
• Consider amiodarone for people with left ventricular impairment or heart failure
• In people with infrequent paroxysms and few symptoms, or if symptoms are induced by known precipitants (such as alcohol, caffeine), a ‘no drug treatment’ strategy or a ‘pill-in-the-pocket’ strategy (in which antiarrhythmic drugs are taken only when an episode starts) should be considered and discussed with the person
• In people with paroxysmal AF, a ‘pill-in-the-pocket’ strategy should be considered for those who:
  • have no history of left ventricular dysfunction, or valvular or ischaemic heart disease and
  • have a history of infrequent symptomatic episodes of paroxysmal AF and
  • have a systolic blood pressure greater than 100 mmHg and a resting heart rate above 70 bpm and
  • are able to understand how to, and when to, take the medication.

Stopping Anticoagulation

• In people with a diagnosis of AF, 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.

Footnote

[A] In April 2021, this was an off-label use of diltiazem. See NICE’s information on prescribing medicines.