Update information

February 2016: Recommendation 1.7.4 has been amended to clarify the populations referred to and their treatment choices.

August 2014: The wording of recommendation 1.7.2 has been clarified, and now refers to people without life-threatening haemodynamic instability.

This guideline updates and replaces NICE clinical guideline 36 (published June 2006). New recommendations have been added for a personalised package of care and information, referral for specialised management, stroke prevention, rate and rhythm control and the management of acute atrial fibrillation.

Recommendations are marked as [2006], [2006, amended 2014], [2010, amended 2012], [2012], [2013] or [new 2014]:

  • [2006] indicates that the evidence has not been reviewed since 2006

  • [2006, amended 2014] indicates that the evidence has not been reviewed since 2007, but changes have been made to the recommendation wording that change the meaning

  • [2010, amended 2012] applies to guidance from NICE technology appraisal 197, published in 2010 and amended in 2012

  • [2012] applies to guidance from NICE technology appraisal 249, published in 2012

  • [2013] applies to guidance from NICE technology appraisal 275, published in 2013

  • [new 2014] indicates that the evidence has been reviewed and the recommendation has been updated or added to.

Recommendations from NICE clinical guideline 36 that have been amended

Recommendations are labelled [2006, amended 2014] if the evidence has not been reviewed but changes have been made to the recommendation wording that change the meaning.

Recommendations 1.6.13 and 1.6.14 (labelled [2010, amended 2012]) are from NICE technology appraisal guidance 197, which was amended and reissued in December 2012 to reflect changes to dronedarone's UK marketing authorisation.

Recommendation in 2006 guideline

Recommendation in current guideline

Reason for change

1.1.4.1 Transthoracic echocardiography (TTE) should be performed in patients with AF:

  • for whom a baseline echocardiogram is important for long‑term management, such as younger patients

  • 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 1.8.6).

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]

'Such as younger patients' has been removed to ensure that all people with atrial fibrillation are included, and not just younger patients, for equality purposes.

The cross‑reference to section 1.8.6 has been amended to cross‑refer to the recommendations on assessment of stroke and bleeding risks and interventions to prevent stroke in the 2014 guideline.

1.1.4.2 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 stroke risk stratification algorithm in the full guideline).

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]

The cross‑reference to the stroke risk stratification algorithm has been amended to cross‑refer to the recommendations on assessment of stroke and bleeding risk and interventions to prevent stroke in the 2014 guideline.

1.2.6.1 In people with acute atrial fibrillation who are receiving no, or subtherapeutic, anticoagulation therapy:

  • in the absence of contraindications, heparin should be started at initial presentation

  • continue heparin until a full assessment has been made and appropriate antithrombotic therapy has been started, based on risk stratification (see section 1.8.6).

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

'Acute' has been amended to 'new‑onset' for clarification and consistency. In the 2006 guideline 'acute' denotes new‑onset atrial fibrillation. In the 2014 guideline 'acute' refers to the nature of the presentation of atrial fibrillation.

The cross‑reference to section 1.8.6 has been amended to cross‑refer to the recommendations on assessment of stroke and bleeding risks and interventions to prevent stroke in the 2014 guideline.

1.3.3.1 Before cardioversion, patients should be maintained on therapeutic

anticoagulation with warfarin (INR 2.5, range 2.0 to 3.0) for a minimum of 3 weeks.

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]

The 2006 recommendation has been updated to make the recommendation more consistent with the pathway of the updated 2014 guideline.

1.6.2.2 In patients with a confirmed diagnosis of acute AF of recent onset (less than 48 hours since onset), oral anticoagulation should be used if:

  • stable sinus rhythm is not successfully restored within the same 48‑hour period following onset of acute AF; or

  • there are factors indicating a high risk of AF recurrence; or

  • it is recommended by the stroke risk stratification algorithm (see appendix E, page 47).

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:

[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

'Acute' has been deleted for clarification and consistency. In the 2006 guideline 'acute' denotes new‑onset atrial fibrillation. In the 2014 guideline 'acute' refers to the nature of the presentation of atrial fibrillation.

The cross‑reference to the stroke risk stratification algorithm has been amended to cross‑refer to the recommendations on assessment of stroke and bleeding risks and interventions to prevent stroke in the 2014 guideline.

1.6.2.3 In patients with acute AF where there is uncertainty over the precise time since onset, oral anticoagulation should be used, as for persistent AF (see section 1.3.3).

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]

'Acute' has been amended to 'new‑onset' for clarification and consistency. In the 2006 guideline 'acute' denotes new‑onset atrial fibrillation. In the 2014 guideline 'acute' refers to the nature of the presentation of atrial fibrillation.

The cross‑reference to the stroke risk stratification algorithm has been amended to cross‑refer to the recommendations on assessment of stroke and bleeding risks and interventions to prevent stroke in the 2014 guideline.

1.7.1.1 In patients undergoing cardiothoracic surgery:

  • the risk of postoperative AF should be reduced by the administration of one of the following:

    • amiodarone

    • a beta‑blocker

    • sotalol

    • a rate‑limiting calcium antagonist

  • digoxin should not be used.

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]

Deleted option of sotalol in the 2014 guideline recommendation because it is no longer recommended as an option.

1.7.1.2 In patients undergoing cardiac surgery on pre‑existing beta‑blocker therapy, this treatment should be continued unless contraindications develop (such as post‑operative bradycardia or hypotension.

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]

'Cardiac' has been amended to 'cardiothoracic' for clarification and consistency. The Guideline Development Group assumes that no distinction between the 2 terms was intended in the 2006 guideline.

1.7.2.2 Unless contraindicated, post‑operative AF following non‑cardiothoracic surgery should be managed as for acute‑onset AF with any other precipitant.

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]

'Acute' has been deleted for clarification and consistency. In the 2006 guideline 'acute' denotes new‑onset atrial fibrillation. In the 2014 guideline 'acute' refers to the nature of the presentation of atrial fibrillation.

  • National Institute for Health and Care Excellence (NICE)