RECOGNITION AND ASSESSMENT
Symptoms (in order of increasing severity/urgency)
- Palpitation
- Dyspnoea
- Chest pain
- Dizziness
- Syncope
- Cardiac arrest
Signs
- Irregular pulse
- Heart rate <60 or >100 beats/min
- Hypotension (systolic BP<100 mmHg)
- Hypoperfusion
- Jugular venous pressure (JVP) elevated
- Variable intensity of first heart sound
- Signs of heart failure
Investigations
- 12-lead ECG. A single-lead rhythm strip is an inferior alternative, but better than no ECG at all
- Urgent U&E
Important differential diagnosis
- Wolff-Parkinson-White (WPW) syndrome can present as AF. QRS complexes will be pre-excited (i.e. wide and bizarre), and ventricular response very fast with a tendency to degenerate to ventricular flutter and fibrillation (VF).
- never give digoxin or verapamil but seek urgent cardiology advice from on-call SpR with a view to restoring sinus rhythm with flecainide or sotalol, or with DC cardioversion
IMMEDIATE TREATMENT
- If patient in peri-arrest situation, follow advanced life support - see Cardiopulmonary resuscitation - life support procedure guideline
Rhythm control
- If AF present for <48 hr, seek urgent cardiology advice
- Give DOACs or LMWH or unfractionated heparin IV – see IV unfractionated heparin guideline (if no contraindications)
- aim is to restore sinus rhythm immediately using DC cardioversion (electrical) or anti-arrhythmic drugs (chemical - amiodarone, flecainide or propafenone), unless there is a persistent underlying cause (e.g. thyrotoxicosis, mitral valve disease, pneumonia). Drugs other than amiodarone carry a risk of pro-arrhythmia and must be used with caution
Rate control
- Once confident not WPW syndrome and if ventricular response to AF rapid during high sympathetic stress (e.g. pneumonia, myocardial infarction or postoperatively) and systolic BP >100 mmHg, options include:
- either a beta-blocker or a rate-limiting calcium channel blocker
- do not give both: check if patient already prescribed either drug
- if rate does not fall sufficiently, add digoxin (for chronic use) – see Digoxin guideline
- Where heart failure is a clinical issue, consider digoxin (see Digoxin guideline) but amiodarone for acute (not chronic) management conveys greater efficacy (contact on-call cardiology re use of amiodarone)
ANTICOAGULATION
- Consider thromboprophylaxis with DOAC or warfarin (maintenance INR 2.5) for ALL patients with sustained or paroxysmal AF or flutter depending on their CHA2DS2VASc score
Choosing for the individual patient
- Weigh the risk of thromboembolic stroke against the adverse risk of bleeding
- Assess the risk of stroke, using the CHA2DS2VASc score
- Assess the risk of major bleeding from anticoagulation (a bleed requiring hospital admission, a blood transfusion or causing stroke) by the ORBIT score and other risk factors:
- congestive heart failure (or LVEF <40%)
- hypertension (ever, treated/untreated)
- labile INR
- alcohol abuse (≥ 8 drinks/week)
- NSAIDs
- ORBIT scoring and other risk factors assess bleeding risk. High scores do not mean patients are contraindicated for anticoagulation but caution and closer monitoring is required
Antiplatelets
- If patient receiving antiplatelet therapies for coronary stent, do NOT discontinue, contact cardiology SpR
ORBIT
Select all items relating to your patient
| Risk factor for bleeding | Points attributed |
|---|---|
| Older (aged ≥75 yr) | 1 point |
| Reduced haemoglobin (<13 mg/dL in men and <12 mg/dL in women), haematocrit (<40% in men and <36% in women) or history of anaemia | 2 points |
| Bleeding history | 2 points |
| Insufficient kidney function (eGFR < 60 mg/dL/1.73 m2) | 1 point |
| Treatment with an antiplatelet agent | 1 point |
Interpretation
| ORBIT Score | Risk group | Bleeds per 100 patient-years |
|---|---|---|
| 0-2 | Low | 2.4 |
| 3 | Medium | 4.7 |
| 4-7 | High | 8.1 |
| Score >3 | Bleeding risk high. Caution and regular review following start of anticoagulation | |
Making decision
- In considering whether to start DOAC or warfarin, discuss with patient and carers the risks and benefits and the need for regular therapy and, in the case of warfarin, INR checks
- If a decision is made not to anticoagulate the patient, document the reason in the notes
SUBSEQUENT MANAGEMENT
Chronic AF
- For rate control, prefer bisoprolol 2.5-10 mg/atenolol 50-100 mg oral daily or (if no LV systolic dysfunction/heart failure) consider calcium antagonist [verapamil 40-80 mg 8-hrly or diltiazem SR up to 300 mg/day (contact pharmacy for advice on dosing/brands)]
- digoxin will control resting rate but not exercise rate
- For thromboembolic risk reduction, see ANTICOAGULATION above
Back in sinus rhythm
- If sinus rhythm restored after recurrent episode of AF with no obvious precipitant (e.g. pneumonia), consider long-term prophylactic therapy
- patients with evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy, or hypertensive disease, use a beta-blocker (e.g. bisoprolol/atenolol). If contraindicated, seek advice from on-call cardiologist SpR
- patients with no evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy, consider Class 1c agent (e.g. propafenone, flecainide) after seeking advice from on-call cardiology SpR
Unsuccessful cardioversion
- If DC or chemical cardioversion unsuccessful, consider long-term control of the ventricular response
- if heart failure present, use digoxin +/- beta-blocker or, if beta-blocker contraindicated, seek cardiology advice from on-call SpR on use of amiodarone
- if no heart failure present, use beta-blocker or, if beta-blocker contraindicated, diltiazem or verapamil
Bradycardia/tachycardia form of sino-atrial disease
- For prevention of AF in the bradycardia/tachycardia form of sino-atrial disease, consider pacing - seek advice from on-call cardiologist SpR
Ablation therapy
- Consider ablation therapy. Refer patients to Electro-physiology consultant with:
- WPW syndrome (ALL patients)
- persistent AF in whom ventricular response cannot be satisfactorily controlled with drug therapy
- recurrent AF
- taking an anti-arrhythmic agent
- paroxysmal AF with symptoms
Alerts on drug combinations
- Avoid combinations of anti-arrhythmic drugs (including beta-blockers, diltiazem and verapamil) except after specific cardiological advice
- Avoid combinations of anti-arrhythmic drugs and diuretics if possible as hypokalaemia worsens pro-arrhythmic potential
DISCHARGE AND FOLLOW-UP
- Do NOT discharge patient from hospital taking rhythm-controlling agents (unless advised to by a cardiologist) as these are unlikely to restore sinus rhythm and expose patient unnecessarily to risk of drug-induced arrhythmia
Follow-up
- If new onset AF, consider cardiology referral for DC cardioversion
- For any patient requiring on-going management of rate/rhythm not under current cardiology follow-up, refer to AF/arrhythmia nurse team
- Otherwise ask for GP review
- Request outpatient echocardiogram
- request follow-up clinician to refer to cardiologist if echocardiogram abnormal
Anticoagulation
- If taking DOAC, ask for GP review in 4 months for renal function/adherence
- If taking warfarin, follow guidance in yellow anticoagulation book
Last reviewed: 2025-10-23