1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

These recommendations apply to adults (aged 18 and over) with suspected or diagnosed atrial fibrillation.

1.1 Diagnosis and assessment

1.1.1 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. [2006]

1.1.2 Perform an electrocardiogram (ECG) in all people, whether symptomatic or not, in whom atrial fibrillation is suspected because an irregular pulse has been detected. [2006]

1.1.3 In people with suspected paroxysmal atrial fibrillation[3] 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. [2006]

1.1.4 Perform transthoracic echocardiography (TTE) in people with atrial fibrillation:

  • 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/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 section 1.4 Assessment of stroke and bleeding risks and section 1.5 Interventions to prevent stroke). [2006, amended 2014]

1.1.5 Do not routinely perform TTE solely for the purpose of further stroke risk stratification in people with atrial fibrillation for whom the need to initiate anticoagulation therapy has already been agreed on appropriate clinical criteria (see section 1.4 Assessment of stroke and bleeding risks and section 1.5 Interventions to prevent stroke). [2006, amended 2014]

1.1.6 Perform transoesophageal echocardiography (TOE) in people with atrial fibrillation:

  • 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 where there is a need to exclude cardiac abnormalities

  • for whom TOE‑guided cardioversion is being considered. [2006]

1.2 Personalised package of care and information

1.2.1 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). [new 2014]

1.2.2 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). [new 2014]

1.3 Referral for specialised management

1.3.1 Refer people promptly[4] at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed. [new 2014]

1.4 Assessment of stroke and bleeding risks

Stroke risk

1.4.1 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 atrial fibrillation

  • atrial flutter

  • a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm. [new 2014]

Bleeding risk

1.4.2 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. [new 2014]

1.4.3 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. [new 2014]

1.4.4 Do not withhold anticoagulation solely because the person is at risk of having a fall. [new 2014]

1.5 Interventions to prevent stroke

1.5.1 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 CHA2DS2-VASc score of 0 for men or 1 for women). [new 2014]

Anticoagulation

Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist.

1.5.2 Consider anticoagulation for men with a CHA2DS2-VASc score of 1. Take the bleeding risk into account. [new 2014]

1.5.3 Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account. [new 2014]

1.5.4 Discuss the options for anticoagulation with the person and base the choice on their clinical features and preferences. [new 2014]

Apixaban

1.5.5 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:

1.5.6 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 international normalised ratio (INR) control.
[This recommendation is from Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation (NICE technology appraisal guidance 275).] [2013]

Dabigatran etexilate

1.5.7 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).] [2012]

1.5.8 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 international normalised ratio (INR) control.
[This recommendation is from Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal guidance 249).] [2012]

Rivaroxaban

1.5.9 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:

1.5.10 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 international normalised ratio (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).] [2012]

Assessing anticoagulation control with vitamin K antagonists

1.5.11 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. [new 2014]

1.5.12 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%. [new 2014]

1.5.13 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. [new 2014]

1.5.14 If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person. [new 2014]

Antiplatelets

1.5.15 Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation. [new 2014]

Review of people with atrial fibrillation

1.5.16 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. [new 2014]

1.5.17 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. [new 2014]

1.5.18 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. [new 2014]

Left atrial appendage occlusion

1.5.19 Consider left atrial appendage occlusion (LAAO) if anticoagulation is contraindicated or not tolerated and discuss the benefits and risks of LAAO with the person. For more information see Percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism (NICE interventional procedure guidance 349). [new 2014]

1.5.20 Do not offer LAAO as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated. [new 2014]

1.6 Rate and rhythm control

When to offer rate or rhythm control

1.6.1 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. [new 2014]

Rate control

1.6.2 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. [new 2014]

1.6.3 Consider digoxin monotherapy for people with non‑paroxysmal atrial fibrillation only if they are sedentary (do no or very little physical exercise). [new 2014]

1.6.4 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. [new 2014]

1.6.5 Do not offer amiodarone for long‑term rate control. [new 2014]

Rhythm control

1.6.6 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. [new 2014]

Cardioversion

1.6.7 For people having cardioversion for atrial fibrillation that has persisted for longer than 48 hours, offer electrical (rather than pharmacological) cardioversion. [new 2014]

1.6.8 Consider amiodarone therapy starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm, and discuss the benefits and risks of amiodarone with the person. [new 2014]

1.6.9 For people with atrial fibrillation of greater than 48 hours' duration, in whom elective cardioversion is indicated:

  • both transoesophageal echocardiography (TOE)‑guided cardioversion and conventional cardioversion should be considered equally effective

  • a TOE‑guided cardioversion strategy should be considered:

    • where experienced staff and appropriate facilities are available and

    • where a minimal period of precardioversion anticoagulation is indicated due to the person's choice or bleeding risks. [2006]

Drug treatment for long‑term rhythm control

1.6.10 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 atrial fibrillation. [new 2014]

1.6.11 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. [new 2014]

1.6.12 If beta‑blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control, taking comorbidities into account. [new 2014]

1.6.13 Dronedarone is recommended as an option for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation:

  • whose atrial fibrillation is not controlled by first‑line therapy (usually including beta‑blockers), that is, as a second‑line treatment option and after alternative options have been considered and

  • who have at least 1 of the following cardiovascular risk factors:

    • hypertension requiring drugs of at least 2 different classes

    • diabetes mellitus

    • previous transient ischaemic attack, stroke or systemic embolism

    • left atrial diameter of 50 mm or greater or

    • age 70 years or older and

  • who do not have left ventricular systolic dysfunction and

  • who do not have a history of, or current, heart failure.
    [This recommendation is from Dronedarone for the treatment of non-permanent atrial fibrillation (NICE technology appraisal guidance 197).] [2010, amended 2012]

1.6.14 People who do not meet the criteria in recommendation 1.6.13 who are currently receiving dronedarone should have the option to continue treatment until they and their clinicians consider it appropriate to stop. [This recommendation is from Dronedarone for the treatment of non-permanent atrial fibrillation (NICE technology appraisal guidance 197).] [2010, amended 2012]

1.6.15 Consider amiodarone for people with left ventricular impairment or heart failure. [new 2014]

1.6.16 Do not offer class 1c antiarrhythmic drugs such as flecainide or propafenone to people with known ischaemic or structural heart disease. [new 2014]

1.6.17 Where people have infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants (such as alcohol, caffeine), a 'no drug treatment' strategy or a 'pill‑in‑the‑pocket' strategy[5] should be considered and discussed with the person. [2006]

1.6.18 In people with paroxysmal atrial fibrillation, 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 atrial fibrillation 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. [2006]

Left atrial ablation and a pace and ablate strategy

Left atrial ablation

1.6.19 If drug treatment has failed to control symptoms of atrial fibrillation or is unsuitable:

  • offer left atrial catheter ablation to people with paroxysmal atrial fibrillation

  • consider left atrial catheter or surgical ablation for people with persistent atrial fibrillation

  • discuss the risks and benefits with the person[6]. [new 2014]

1.6.20 Consider left atrial surgical ablation at the same time as other cardiothoracic surgery for people with symptomatic atrial fibrillation[7]. [new 2014]

Pace and ablate strategy

1.6.21 Consider pacing and atrioventricular node ablation for people with permanent atrial fibrillation with symptoms or left ventricular dysfunction thought to be caused by high ventricular rates. [new 2014]

1.6.22 When considering pacing and atrioventricular node ablation, reassess symptoms and the consequent need for ablation after pacing has been carried out and drug treatment further optimised. [new 2014]

1.6.23 Consider left atrial catheter ablation before pacing and atrioventricular node ablation for people with paroxysmal atrial fibrillation or heart failure caused by non‑permanent (paroxysmal or persistent) atrial fibrillation. [new 2014]

1.7 Management for people presenting acutely with atrial fibrillation

Rate and rhythm control

1.7.1 Carry out emergency electrical cardioversion, without delaying to achieve anticoagulation, in people with life‑threatening haemodynamic instability caused by new‑onset atrial fibrillation. [new 2014]

1.7.2 In people with atrial fibrillation presenting acutely without life‑threatening haemodynamic instability, offer rate or rhythm control if the onset of the arrhythmia is less than 48 hours, and start rate control if it is more than 48 hours or is uncertain. [new 2014]

1.7.3 Consider either pharmacological or electrical cardioversion depending on clinical circumstances and resources in people with new‑onset atrial fibrillation who will be treated with a rhythm control strategy. [new 2014]

1.7.4 If pharmacological cardioversion has been agreed on clinical and resource grounds for new‑onset atrial fibrillation, offer:

  • A choice of flecainide or amiodarone to people with no evidence of structural or ischaemic heart disease or

  • amiodarone to people with evidence of structural heart disease. [new 2014]

1.7.5 In people with atrial fibrillation in whom the duration of the arrhythmia is greater than 48 hours or uncertain and considered for long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks. During this period offer rate control as appropriate. [2006, amended 2014]

1.7.6 Do not offer magnesium or a calcium‑channel blocker for pharmacological cardioversion. [new 2014]

Anticoagulation

1.7.7 In people with new‑onset atrial fibrillation who are receiving no, or subtherapeutic, anticoagulation therapy:

1.7.8 In people with a confirmed diagnosis of atrial fibrillation of recent onset (less than 48 hours since onset), offer oral anticoagulation if:

1.7.9 In people with new‑onset atrial fibrillation where there is uncertainty over the precise time since onset, offer oral anticoagulation as for persistent atrial fibrillation (see section 1.4 Assessment of stroke and bleeding risks and section 1.5 Interventions to prevent stroke). [2006, amended 2014]

1.8 Initial management of stroke and atrial fibrillation

1.8.1 For guidance on the initial management of stroke and atrial fibrillation see recommendation 1.4.3.1 in 'Stroke' (NICE clinical guideline 68). [new 2014]

1.9 Prevention and management of postoperative atrial fibrillation

1.9.1 In people undergoing cardiothoracic surgery:

  • reduce the risk of postoperative atrial fibrillation by offering 1 of the following:

    • amiodarone

    • a standard beta‑blocker (that is, a beta‑blocker other than sotalol)

    • a rate‑limiting calcium antagonist

  • do not offer digoxin. [2006, amended 2014]

1.9.2 In people undergoing cardiothoracic surgery on pre‑existing beta‑blocker therapy, continue this treatment unless contraindications develop (such as postoperative bradycardia or hypotension). [2006, amended 2014]

1.9.3 Unless contraindicated, offer a rhythm‑control strategy as the initial management option for the treatment of postoperative atrial fibrillation following cardiothoracic surgery. [2006, amended 2014]

1.9.4 Unless contraindicated, manage postoperative atrial fibrillation following non‑cardiothoracic surgery as for new‑onset atrial fibrillation with any other precipitant. [2006, amended 2014]

1.9.5 In the prophylaxis and management of postoperative atrial fibrillation, use appropriate antithrombotic therapy and correct identifiable precipitants (such as electrolyte imbalance or hypoxia). [2006, amended 2014]



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

[4] 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.

[5] A 'pill‑in‑the‑pocket' strategy is defined as the person managing paroxysmal atrial fibrillation themselves by taking antiarrhythmic drugs only when an episode of atrial fibrillation starts.

[6] For more information on left atrial catheter ablation see Percutaneous balloon cryoablation for pulmonary vein isolation in atrial fibrillation (NICE interventional procedure guidance 427), Percutaneous endoscopic catheter laser balloon pulmonary vein isolation for atrial fibrillation (NICE interventional procedure guidance 399) and Percutaneous (non-thoracoscopic) epicardial catheter radiofrequency ablation for atrial fibrillation (NICE interventional procedure guidance 294). For more information on left atrial surgical ablation without thoracotomy see Thoracoscopic epicardial radiofrequency ablation for atrial fibrillation (NICE interventional procedure guidance 286).

[7] For more information on left atrial surgical ablation at the same time as other cardiothoracic surgery see High-intensity focused ultrasound for atrial fibrillation in association with other cardiac surgery (NICE interventional procedure guidance 184), Cryoablation for atrial fibrillation in association with other cardiac surgery (NICE interventional procedure guidance 123), Microwave ablation for atrial fibrillation in association with other cardiac surgery (NICE interventional procedure guidance 122) and Radiofrequency ablation for atrial fibrillation in association with other cardiac surgery (NICE interventional procedure guidance 121).

[8] Factors indicating a high risk of atrial fibrillation recurrence include: a history of failed attempts at cardioversion; structural heart disease (mitral valve disease, left ventricular dysfunction or an enlarged left atrium); a prolonged history of atrial fibrillation (more than 12 months); previous recurrences of atrial fibrillation.

  • National Institute for Health and Care Excellence (NICE)