Atrial fibrillation: diagnosis and management

The evidence did not support changing the recommended diagnostic tests to either replace 12‑lead ECG as the test to confirm persistent atrial fibrillation or replace pulse palpation as the initial step for persistent atrial fibrillation in a 2‑step strategy. The committee clarified that 12‑lead ECG should be used as the test to confirm atrial fibrillation, to prevent the use of less accurate ECG devices, such as mobile and lead‑I ECG devices. The committee agreed that, although the evidence showed that accuracy varied, there was some evidence that new devices were accurate and showed promise. It was noted that NICE has produced diagnostics guidance on lead-I ECG devices for detecting symptomatic atrial fibrillation using single time point testing in primary care. The committee made a research recommendation on tests to diagnose persistent atrial fibrillation to encourage further high‑quality research in this area to guide future practice.

Full details of the evidence and the committee's discussion are in evidence review B: accuracy of tests for detection.

The committee agreed that the evidence on tests to detect paroxysmal atrial fibrillation was not clear enough to warrant a change in practice from the 2014 recommendation. However, the evidence did show that longer durations of detection increased accuracy. The committee made a research recommendation on tests to diagnose paroxysmal atrial fibrillation.

Full details of the evidence and the committee's discussion are in evidence review B: accuracy of tests for detection.

There was limited evidence on whether to continue anticoagulation or to stop it and switch to aspirin after successful treatment of atrial fibrillation by catheter ablation. The committee agreed that the evidence was insufficient and that there was too much uncertainty in the results to make a recommendation based on the evidence. The committee therefore developed research recommendations on stopping anticoagulation after ablation and stopping anticoagulation after resolution of postoperative atrial fibrillation to encourage further research.

The committee was concerned about the potential withdrawal of anticoagulation in people who had not had ablation or cardiac surgery for atrial fibrillation, but in whom sinus rhythm is now present and atrial fibrillation is no longer detectable. In particular, the committee noted that paroxysmal atrial fibrillation is not always detectable. Based on their experience, the committee made a consensus‑based recommendation to ensure that decisions about stopping anticoagulation in this population are based on formal risk assessment of stroke and bleeding risks and patient preference.

Full details of the evidence and the committee's discussion are in evidence review H: discontinuing anticoagulation in people whose atrial fibrillation has resolved.

There was limited evidence on whether to continue anticoagulation or to stop it and switch to aspirin after successful treatment of atrial fibrillation by catheter ablation. The committee agreed that the evidence was insufficient and that there was too much uncertainty in the results to make a recommendation based on the evidence. The committee therefore developed research recommendations on stopping anticoagulation after ablation and stopping anticoagulation after resolution of postoperative atrial fibrillation to encourage further research.

The committee was concerned about the potential withdrawal of anticoagulation in people who had not had ablation or cardiac surgery for atrial fibrillation, but in whom sinus rhythm is now present and atrial fibrillation is no longer detectable. In particular, the committee noted that paroxysmal atrial fibrillation is not always detectable. Based on their experience, the committee made a consensus‑based recommendation to ensure that decisions about stopping anticoagulation in this population are based on formal risk assessment of stroke and bleeding risks and patient preference.

Full details of the evidence and the committee's discussion are in evidence review H: discontinuing anticoagulation in people whose atrial fibrillation has resolved.