Related guidance:
Identifying risk factors for developing a long QT interval (SPS)
Atrial fibrillation (CKS March 2023)
Algorithms for atrial fibrillation: diagnosis and management (NICE April 2021)
Atrial fibrillation: diagnosis and management NICE guideline (NG196 April 2021, updated June 2021)
Detection and diagnosis
- 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. - 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.
- 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.
Assessment of stroke and bleeding risks
- 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.
Bleeding risk
- 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 (HAS-BLED). - Offer monitoring and support to modify risk factors for bleeding, including:
• uncontrolled hypertension
• poor control of international normalised ratio (INR) in patients on vitamin K antagonists
• concurrent medication, including antiplatelets, selective serotonin reuptake inhibitors (SSRIs) and non-steroidal anti-inflammatory drugs (NSAIDs)
• harmful alcohol consumption
• reversible causes of anaemia. - 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.
Assessment of cardiac function
- 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 - 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.
- 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.
Personalised package of care and information
- 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
－ support networks.
Atrial fibrillation (AF) : causes, symptoms and treatments
Atrial fibrillation Your quick guide
Referral for specialised management
- 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.
Anticoagulation
- 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. - When deciding between anticoagulation treatment options:
• Discuss the risks and benefits of different drugs with the person
• Take into account any contraindications for each drug and follow the guidance in the British National Formulary and the MHRA advice on direct-acting oral anticoagulants, in particular for advice on dosages in people with renal impairment, reversal agents and monitoring. - 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.
- 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.
For anticoagulants see NHS Somerset Formulary Blood Clots.
- If direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist.
- 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.
- 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).
- Do not withhold anticoagulation solely because of a person’s age or their risk of falls.
Assessing anticoagulation control with vitamin K antagonists
- 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. - 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%. - 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. - If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person.
Antiplatelets
- Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation.
For antiplatelets see NHS Somerset Formulary Blood Clots.
Review of people with atrial fibrillation
- 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. - 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.
- 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.
Left atrial appendage occlusion
- Consider left atrial appendage occlusion (LAAO) if anticoagulation is contraindicated or not tolerated and discuss the benefits and risks of LAAO with the person.
- Do not offer LAAO as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated.
Rate control
- 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. - 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 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 (off-label use of diltiazem). - 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.
- 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. - 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:
• a beta-blocker
• diltiazem
• digoxin.
(off-label use of diltiazem). - Do not offer amiodarone for long-term rate control. There is a lack of evidence on long-term rate control, and numerous serious side effects associated with the long-term use of amiodarone (including thyroid, lung and nerve damage), many of which are irreversible. Amiodarone should only be used as an interim therapy, for example while waiting for cardioversion, and would not usually be taken for longer than 12 months.
Rhythm control
- 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.
For beta-blockers and diltiazem see NHS Somerset Formulary Blood pressure conditions.
Antiarrhythmic drug therapy
- 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.
- Do not offer class 1c antiarrhythmic drugs such as flecainide or propafenone to people with known ischaemic or structural heart disease.
- 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.
- If beta-blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control, taking comorbidities into account.
- 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.
- Consider amiodarone for people with left ventricular impairment or heart failure.
- 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.
- 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.
Cardioversion
- For people having cardioversion for atrial fibrillation that has persisted for longer than 48 hours, offer electrical (rather than pharmacological) cardioversion.
- 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.
- 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.
Left atrial ablation
- 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. - 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.
- Consider left atrial surgical ablation at the same time as other cardiothoracic surgery for people with symptomatic atrial fibrillation.
Preventing recurrence after ablation
- 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.
- Reassess the need for antiarrhythmic drug treatment at 3 months after left atrial ablation.
Pace and ablate strategy
- 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.
- 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.
- 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.
Stopping anticoagulation
- In people with a diagnosis of atrial fibrillation, do not stop anticoagulation solely because atrial fibrillation is no longer detectable.
- 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.
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Antiarrhythmics | |||
| Class 1C | Flecainide | 50mg tablet: £2.56 (60) | NHS Somerset classify as Amber (initiated by specialist). |
| 100mg tablet: £4.22 (60) | |||
| Class 3 | Amiodarone | 100mg tablet: £1.86 | NHS Somerset classify as Amber as per traffic light guidance (initiated by specialist) for the treatment of severe rhythm disorders not responding to other therapies. Prescribing at initial loading dose should be limited to 2 weeks and provided by specialist. Care should be taken to ensure that only the ongoing dose is used for prescribing by any other doctor. See SPS Amiodarone monitoring. Do not exceed Simvastatin 20mg if taking with amiodarone and monitor lipid levels to ensure lowest dose necessary of simvastatin is used. |
| 200mg tablet: £1.65 | |||
| Amiodarone has been associated with serious and potentially life-threatening side effects, particularly of the lung, liver, and thyroid gland. We remind healthcare professionals that patients should be supervised and reviewed regularly during treatment. Lung problems may have slow onset but then progress rapidly. Computerised tomography scans may help to confirm a suspected diagnosis of pulmonary toxicity. See MHRA Drug Safety Update (March 2022) for Amiodarone (Cordarone X): reminder of risks of treatment and need for patient monitoring and supervision. | |||
| A patient card is available for all patients that take amiodarone. This card includes important information on the most serious and potentially life-threatening side-effects (and their symptoms) that may occur during treatment with amiodarone and also reminds patients of the potential for drug to drug interactions. See MHRA Drug Safety Update (May 2022) | |||
| Dronedarone as Multaq® | 400mg tablets: £67.50 (60) | NHS Somerset classify as Amber as per traffic light guidance 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. Regular monitoring of cardiac, liver, and renal function during treatment is recommended. |
|
| Following new evidence of cardiovascular, hepatic and pulmonary risk, a review of dronedarone has concluded that the benefits of treatment continue to outweigh the risks for the maintenance of sinus rhythm after successful cardioversion in a limited population of patients with paroxysmal or persistent atrial fibrillation; however, in light of safety concerns dronedarone should only be prescribed after other treatment options have been considered. To support safer use, patients should have their treatment reviewed at the next routine appointment to ensure that they remain eligible for dronedarone treatment according to the revised prescribing information, including new restrictions on use. Regular monitoring of cardiac, liver, and renal function during treatment is recommended. See MHRA Drug Safety Update (December 2014) for Dronedarone: cardiovascular, hepatic and pulmonary adverse events – new restrictions and monitoring requirements. | |||
| Cardiac glycoside | Digoxin | 62.5microgram tablet: £1.54 | 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. For worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure. Seek specialist advice before initiating. Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8 to 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non‑adherence. The serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the 'therapeutic range'. If the person's eGFR is 45 ml/min/1.73 m2 or below, consider lower doses and/or slower titration of dose of ACE inhibitors or ARBs, MRA and digoxin. Monitoring serum potassium is particularly important if a person is taking digoxin or an MRA. See SPS Digoxin monitoring. |
| 125microgram tablet: £1.56 | |||
| 250microgram tablet: £1.57 | |||
| 50micrograms/ml oral solution: £5.35 (60ml) | |||