Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Detection and diagnosis

1.1.1 Perform manual pulse palpation to assess for the presence of an irregular pulse if there is a suspicion of atrial fibrillation. This includes people presenting with any of the following:

  • breathlessness

  • palpitations

  • syncope or dizziness

  • chest discomfort

  • stroke or transient ischaemic attack. [2006]

1.1.2 Perform a 12‑lead electrocardiogram (ECG) to make a diagnosis of atrial fibrillation if an irregular pulse is detected in people with suspected atrial fibrillation with or without symptoms. [2021]

1.1.3 In people with suspected paroxysmal atrial fibrillation 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 atrial fibrillation if symptomatic episodes are more than 24 hours apart. [2021]

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on detection and diagnosis.

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

1.2 Assessment of stroke and bleeding risks

Stroke risk

1.2.1 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 or catheter ablation. [2021]

    See the section on review of people with atrial fibrillation for advice on reassessment of stroke risk.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on stroke risk.

Full details of the evidence and the committee's discussion are in evidence review C and D: tools to predict stroke in people with atrial fibrillation.

Bleeding risk

1.2.2 Assess the risk of bleeding when:

  • considering starting anticoagulation in people with atrial fibrillation 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. [2021]

1.2.3 Offer monitoring and support to modify risk factors for bleeding, including:

Discussing the results of the risk assessment

1.2.4 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. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on bleeding risk.

Full details of the evidence and the committee's discussion are in evidence review E and F: risk stratification tools for predicting bleeding in people with atrial fibrillation.

1.3 Assessment of cardiac function

1.3.1 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 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 section 1.2 on assessment of stroke and bleeding risks and section 1.6 on stroke prevention). [2006, amended 2014]

1.3.2 Do not routinely perform TTE solely for the purpose of further stroke risk stratification in people with atrial fibrillation for whom the need to start anticoagulation therapy has already been agreed on appropriate clinical criteria (see section 1.2 on assessment of stroke and bleeding risks and section 1.6 on stroke prevention). [2006, amended 2014]

1.3.3 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 when there is a need to exclude cardiac abnormalities

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

1.4 Personalised package of care and information

1.4.1 Offer people with atrial fibrillation a personalised package of care. Ensure that the package of care is documented and delivered, and that it covers:

Medicines adherences and optimisation

1.4.3 To support adherence and ensure safe and effective medicines use in people with atrial fibrillation, follow the recommendations in NICE's guidelines on medicines adherence and medicines optimisation. [2021]

1.5 Referral for specialised management

1.5.1 Refer people promptly at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed. This should be within 4 weeks after the failed treatment or after recurrence of atrial fibrillation after cardioversion. [2014]

1.6 Stroke prevention

Anticoagulation

1.6.1 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. [2021]

1.6.2 When deciding between anticoagulation treatment options:

1.6.3 Offer anticoagulation with a direct‑acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2‑VASc score of 2 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 atrial fibrillation. [2021]

1.6.4 Consider anticoagulation with a direct‑acting oral anticoagulant for men with atrial fibrillation and a CHA2DS2‑VASc score of 1, 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 atrial fibrillation). [2021]

1.6.5 If direct‑acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist. See the section on self-monitoring and self-management of vitamin K antagonists. [2021].

1.6.6 For adults with atrial fibrillation 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. [2021]

1.6.7 Do not offer stroke prevention therapy with anticoagulation 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). [2021]

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on stroke prevention.

Full details of the evidence and the committee's discussion are in evidence review G1: anticoagulant therapy for stroke prevention in people with atrial fibrillation and evidence review G2: anticoagulant therapy health economics analysis.

Assessing anticoagulation control with vitamin K antagonists

1.6.9 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. [2014]

1.6.10 Reassess anticoagulation for a person whose anticoagulation is poorly controlled 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%. [2014]

1.6.11 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. [2014]

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

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.

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

Review of people with atrial fibrillation

1.6.14 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. [2014]

1.6.15 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. [2014]

1.6.16 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. [2014]

Left atrial appendage occlusion

1.6.17 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 NICE's interventional procedure guidance on percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism. [2014]

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

1.7 Rate and rhythm control

This section covers rate and rhythm control in non‑acute settings. See section 1.8 for rate and rhythm control for people presenting acutely (either new onset or destabilisation of existing atrial fibrillation).

Rate control

1.7.1 Offer rate control as the first‑line treatment strategy for 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. [2014]

1.7.2 Offer either a standard beta‑blocker (that is, a beta‑blocker other than sotalol) or a rate‑limiting calcium‑channel blocker (diltiazem or verapamil) as initial rate‑control monotherapy to people with atrial fibrillation unless the person has the features described in recommendation 1.7.4. Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences. [2021]

In April 2021, this was an off‑label use of diltiazem. See NICE's information on prescribing medicines.

1.7.3 For people with atrial fibrillation 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. [2021]

1.7.4 Consider digoxin monotherapy for initial rate control for people with non‑paroxysmal atrial fibrillation 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. [2021]

1.7.5 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 2 of the following:

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

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on rate control.

Full details of the evidence and the committee's discussion are in evidence review I: non-ablative rate control therapies.

Rhythm control

1.7.7 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. [2014]

Antiarrhythmic drug therapy

1.7.8 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. [2014]

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

1.7.10 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. [2014]

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

1.7.12 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 atrial fibrillation. [2014]

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

1.7.14 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. [2006]

1.7.15 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]

Cardioversion

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

1.7.17 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. [2014]

1.7.18 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:

    • if experienced staff and appropriate facilities are available and

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

Left atrial ablation

1.7.19 If drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic paroxysmal or persistent atrial fibrillation:

  • consider radiofrequency point‑by‑point ablation or

  • if radiofrequency point‑by‑point ablation is assessed as being unsuitable, consider cryoballoon ablation or laser balloon ablation. [2021]

1.7.20 When considering left atrial ablation, discuss the risks and benefits and take into account the person's preferences. In particular, explain that the procedure is not always effective and that the resolution of symptoms may not be long‑lasting. [2021]

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

For NICE interventional procedures guidance on left atrial ablation for atrial fibrillation, see left atrial ablation in the NICE Pathway on rate and rhythm control of non-acute atrial fibrillation.

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on left atrial ablation.

Full details of the evidence and the committee's discussion are in evidence review J1: ablation, evidence review J2: ablation network meta-analysis and evidence review J3: ablation cost-effectiveness analysis.

Preventing recurrence after ablation

1.7.22 Consider antiarrhythmic drug treatment for 3 months after left atrial ablation to prevent recurrence of atrial fibrillation, taking into account the person's preferences, and the risks and potential benefits. [2021]

1.7.23 Reassess the need for antiarrhythmic drug treatment at 3 months after left atrial ablation. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preventing recurrence after ablation.

Full details of the evidence and the committee's discussion are in evidence review K: antiarrhythmic drugs after ablation.

Pace and ablate strategy

1.7.24 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. [2014]

1.7.25 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. [2014]

1.7.26 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. [2014]

1.8 Management for people presenting acutely with atrial fibrillation

Rate and rhythm control for people presenting acutely

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

1.8.2 In people with atrial fibrillation presenting acutely without life-threatening haemodynamic instability:

  • offer either rate or rhythm control if the onset of the arrhythmia is less than 48 hours

  • offer rate control if onset is more than 48 hours or is uncertain. [2014]

1.8.3 In people with atrial fibrillation presenting acutely with suspected concomitant acute decompensated heart failure, seek senior specialist input on the use of beta‑blockers and do not use calcium‑channel blockers. [2021]

1.8.4 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. [2014]

1.8.5 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. [2014]

1.8.6 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]

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

For a short explanation of why the committee made the 2021 recommendation and how it might affect practice, see the rationale and impact section on rate and rhythm control for people presenting acutely.

Full details of the evidence and the committee's discussion are in evidence review I: non-ablative rate control therapies.

Anticoagulation for people presenting acutely with atrial fibrillation

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

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

  • stable sinus rhythm is not successfully restored within the same 48‑hour period after onset of atrial fibrillation or

  • there are factors indicating a high risk of atrial fibrillation recurrence, including history of failed cardioversion, structural heart disease, prolonged atrial fibrillation (more than 12 months), or previous recurrences or

  • it is recommended in section 1.2 on assessment of stroke and bleeding risks and section 1.6 on stroke prevention. [2006, amended 2014]

1.8.10 In people with new‑onset atrial fibrillation, if there is uncertainty over the precise time since onset, offer oral anticoagulation as for persistent atrial fibrillation (see section 1.2 on assessment of stroke and bleeding risks and section 1.6 stroke prevention). [2006, amended 2014]

1.9 Initial management of stroke and atrial fibrillation

1.9.1 For guidance on the initial management of stroke and atrial fibrillation see recommendation 1.4.17 in NICE's guideline on stroke and transient ischaemic attack in over 16s. [2014]

1.10 Preventing and managing postoperative atrial fibrillation

Preventing postoperative atrial fibrillation

1.10.1 In people having 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‑channel blocker (diltiazem or verapamil)

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

    In April 2021, this was an off‑label use of diltiazem. See NICE's information on prescribing medicines.

1.10.2 In people having cardiothoracic surgery who are already on beta‑blocker therapy, continue this treatment unless contraindications develop (such as postoperative bradycardia or hypotension). [2006, amended 2014]

1.10.3 Do not start statins in people having cardiothoracic surgery solely to prevent postoperative atrial fibrillation. [2021]

1.10.4 In people having cardiothoracic surgery who are already on statins, continue this treatment. For further advice on statins for the prevention of cardiovascular disease, see NICE's guideline on cardiovascular disease: risk assessment and reduction. [2021]

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on preventing postoperative atrial fibrillation.

Full details of the evidence and the committee's discussion are in evidence review M: statins for preventing atrial fibrillation after cardiothoracic surgery.

Managing postoperative atrial fibrillation

Atrial fibrillation after cardiothoracic surgery

1.10.5 Consider either a rhythm‑control or rate‑control strategy for the initial treatment of new‑onset postoperative atrial fibrillation after cardiothoracic surgery. [2021]

1.10.6 If a rhythm‑control strategy is chosen, reassess the need for antiarrhythmic drug treatment at a suitable time point (usually at around 6 weeks). [2021]

Atrial fibrillation after non-cardiothoracic surgery

1.10.7 Manage postoperative atrial fibrillation after non‑cardiothoracic surgery in the same way as for new-onset atrial fibrillation with any other cause. [2006, amended 2014]

Antithrombotic therapy for postoperative atrial fibrillation

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

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on managing atrial fibrillation after cardiothoracic surgery.

Full details of the evidence and the committee's discussion are in evidence review L: treatment strategies for atrial fibrillation after cardiothoracic surgery.

1.11 Stopping anticoagulation

1.11.1 In people with a diagnosis of atrial fibrillation, do not stop anticoagulation solely because atrial fibrillation is no longer detectable. [2021]

1.11.2 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. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on stopping anticoagulation.

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

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

People with atrial fibrillation presenting acutely

People presenting with atrial fibrillation of definite recent onset or with destabilisation of existing atrial fibrillation. This does not include people with atrial fibrillation that has been discovered incidentally, for example through pulse palpitation before routine blood pressure measurement.

Pill-in-the-pocket strategy

The person self‑manages paroxysmal atrial fibrillation by taking antiarrhythmic drugs only when an episode of atrial fibrillation starts.

Paroxysmal atrial fibrillation

Episodes of atrial fibrillation that stop within 7 days, usually within 48 hours, without any treatment.

  • National Institute for Health and Care Excellence (NICE)