Login
Search

Search
Search

Atrial Fibrillation (AF)

NICE guideline [NG196] Atrial fibrillation: diagnosis and management. Last updated: Jun 2021.

Background Information

  • Paroxysmal AF: last 30 sec to 7 days
  • Persistent AF: last >7 days but can be electrically / pharmacologically cardioverted
  • Permanent AF: last >7 days but resistant to cardioversion / not appropriate

Guidelines

Follow peri-arrest tachycardia management.

In short:
  • Unstable → synchronised DC cardioversion
  • Stable
    • <48 hours → rate or rhythm control
    • >48 hours → rate control with beta blockers

See the article for more details.

There are 2 main aspects of the long-term managemnet of AF.
 

There are 2 main approaches to choose from 1) rate and 2) rhythm control
 

1st line is typically rate control for most patients
  • If rate control alone is inadequate → proceed to rhythm control

Few exceptions where rhythm control is preferred as 1st line:
  • New onset AF (<48 hours onset)
  • Heart failure secondary to AF
  • Presence of a reversible cause
  • Rate control not inappropriate
  • AF with atrial flutter deemed suitable for ablation strategy
 

1st line: monotherapy of standard cardioselective beta blocker or non-DHP CCB (diltiazem / verapamil)
  • If AF + heart failure: beta blocker is preferred
  • Digoxin monotherapy is a 1st line alternative in those who do little physical activity

2nd line: dural therapy from standard beta blocker / diltiazem / digoxin
 

Do not offer amiodarone for long-term rate control. [2021]

There are 3 main options of rhythm control:
  • Electrical rhythm control
  • Pharmacological rhythm control
  • Cardiac catheterisation interventions - usually last line

Electrical cardioversion is generally preferred (if rhythm control is opted for), especially if AF persisted for >48 hours and if rapid cardioversion is needed
  • However many clinical and patient factors can influence the decision of which rhythm control method to opt for.
  • In exams, apart from an unstable patient needing immediate cardioversion, it is uncommon for the question to ask the student to choose between methods of rhythm control. Instead it is more common for the question to test one's knowledge on individual cardioversion methods such as which drug to use and precautions. 
 

If AF onset is <48 hours → cardioversion can be carried out now with prior heparin loading

If AF onset is >48 hours, precautions must be taken:
  • Give 3 weeks of anticoagulation prior conversion, or
  • Preform TOETransoesophageal echocardiography to exclude a left atrial thrombus → then give heparin and cardiovert now

 

The reason extra precautions is needed prior cardioversion in those with AF osnet >48 hours is because after 48 hours it is likely a left atrial thrombus as been formed. If the patient is cardioverted immediately without any anticoagulation, the cardioversion is likely to dislodge the left atrial thrombus and cause an embolic stroke.

Rhythm control option Sub-options Recommendations
Electrical n/a Synchronised DC cardioversion
  • Under sedation or GAGeneral anaesthesia, and
  • Under precautions as described above

Consider amiodarone starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm
Pharmacological Cardioversion (immediate restore of sinus rhythm)
  • 1st line: flecainide
  • If presence of ischaemic / structural heart disease: amiodarone
Long-term maintenance therapy
  • 1st line: standard cardioselective beta blocker
  • 2nd line: dronedarone
  • Consider amiodarone in heart failure / left ventricular impairment

Consider pill in the pocket / no drug treatment if infrequent paroxysms and few symptoms OR induced by known precipitants
Cardiac catheterisation interventions Left atrial ablation (pulmonary vein isolation)
  • Requires 4 weeks of anticoagulation prior, and at least 2 months of anticoagulation after
Pace and ablate Pacemaker implanted before AV node ablation
  • For those with symptomatic AF thought to be caused by uncontrolled ventricular rate
 

The drug class of choice to reduce stroke risk in AF is anticoagulants, the decision is mainly influenced by balancing the risk of stroke and risk of bleeding.
 

The CHA2DS2VSc score is recommended to assess the risk of stroke in AF:
  • Male
    • Score 1: consider anticoagulation
    • Score ≥2: offer anticoagulation
  • Female
    • Score ≥2: offer anticoagulation
 
Factor Score
Congestive heart failure 1
Hypertension 1
Age (65-74 y/o) 1
Age (≥75 y/o) 2
Diabetes 1
Stroke / TIATransient ischaemic attack / thromboembolism 2
Vascular disease (IHDIschaemic heart disease, PADPeripheral arterial disease) 1
Sex (female) 2
 

NICE recommends the ORBIT score

  • But there are no recommendations on using the score to guide to give anticoagulation or not
  • Clinical judgement should be used, while taking into patient's wishes

1st line for most patients: DOACsDirect oral anticoagulants (apixaban / rivaroxaban / dabigatran / edoxaban)
  • In the context of renal impairment, apixaban is preferred
  • NB that warfarin is 1st line in valvular AF (i.e. AF with mechanical heart valve or moderate to severe aortic stenosis)

2nd line: warfarin

If anticoagulation is not appropriate: left atrial appendage occlusion
 

Do not withhold anticoagulation solely because of a person's age or their risk of falls. [2021]

References

Author: Adams Lau
Reviewer:
Last edited: 27/07/25