This specialist Guidelines summary provides recommendations on diagnosing and managing atrial fibrillation in adults. It includes guidance on providing the best care and treatment for people with atrial fibrillation, including assessing and managing risks of stroke and bleeding. This summary is intended for use in a secondary care setting by cardiologists.
The recommendations in this guideline were developed before the COVID-19 pandemic.
See the Medicines and Healthcare products Regulatory Agency advice on warfarin and other anticoagulants—monitoring of patients during the COVID-19 pandemic, which includes reports of supratherapeutic anticoagulation with warfarin.
This summary covers left atrial appendage occlusion, cardioversion, left atrial ablation, preventing recurrence after ablation, pace and ablate strategy, management for people presenting acutely with atrial fibrillation, initial management of stroke and atrial fibrillation, and preventing and managing postoperative atrial fibrillation. This summary does not include recommendations in the following areas:
- detection and diagnosis
- assessment of stroke and bleeding risks
- assessment of cardiac function
- personalised package of care and information
- referral for specialised management
- stopping anticoagulation.
Stroke Prevention
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. 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.
- Do not offer LAAO as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated.
Rate and Rhythm Control
Cardioversion
- For people having cardioversion for atrial fibrillation (AF) 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 AF 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 AF:
- 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 AF.
Preventing Recurrence After Ablation
- Consider antiarrhythmic drug treatment for 3 months after left atrial ablation to prevent recurrence of AF, 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 AF 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 AF or heart failure caused by non-permanent (paroxysmal or persistent) AF.
Management for People Presenting Acutely With Atrial Fibrillation
Rate and Rhythm Control for People Presenting Acutely
- Carry out emergency electrical cardioversion, without delaying to achieve anticoagulation, in people with life-threatening haemodynamic instability caused by new-onset AF.
- In people with AF 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.
- In people with AF 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.
- Consider either pharmacological or electrical cardioversion depending on clinical circumstances and resources in people with new-onset AF who will be treated with a rhythm-control strategy.
- If pharmacological cardioversion has been agreed on clinical and resource grounds for new-onset AF, 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.
- In people with AF 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.
- Do not offer magnesium or a calcium-channel blocker for pharmacological cardioversion.
Anticoagulation for People Presenting Acutely With Atrial Fibrillation
- In people with new-onset atrial fibrillation who are receiving no, or subtherapeutic, anticoagulation therapy:
- in the absence of contraindications, offer heparin at initial presentation
- continue heparin until a full assessment has been made and appropriate antithrombotic therapy has been started, based on risk stratification (see the sections on Assessment of Stroke and Bleeding Risks, and Stroke Prevention in full guideline).
- In people with a confirmed diagnosis of AF 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 AF or
- there are factors indicating a high risk of AF recurrence, including history of failed cardioversion, structural heart disease, prolonged AF (more than 12 months), or previous recurrences or
- it is recommended in the sections on Assessment of Stroke and Bleeding Risks, and Stroke Prevention in the full guideline.
Initial Management of Stroke and Atrial Fibrillation
- For guidance on the initial management of stroke and AF see recommendation on anticoagulation treatment for other comorbidities in NICE's guideline on stroke and transient ischaemic attack in over 16s.
Preventing and Managing Postoperative Atrial Fibrillation
Preventing Postoperative Atrial Fibrillation
- In people having cardiothoracic surgery:
- reduce the risk of postoperative AF by offering one of the following:
- amiodarone
- a standard beta-blocker (that is, a beta-blocker other than sotalol)
- a rate-limiting calcium-channel blocker (diltiazem[A] or verapamil)
- do not offer digoxin.
- reduce the risk of postoperative AF by offering one of the following:
- In people having cardiothoracic surgery who are already on beta-blocker therapy, continue this treatment unless contraindications develop (such as postoperative bradycardia or hypotension).
- Do not start statins in people having cardiothoracic surgery solely to prevent postoperative atrial fibrillation.
- 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.
Managing Postoperative Atrial Fibrillation
Atrial Fibrillation after Cardiothoracic Surgery
- Consider either a rhythm-control or rate-control strategy for the initial treatment of new-onset postoperative atrial fibrillation after cardiothoracic surgery.
- If a rhythm-control strategy is chosen, reassess the need for antiarrhythmic drug treatment at a suitable time point (usually at around 6 weeks).
Atrial Fibrillation after Non-cardiothoracic Surgery
- Manage postoperative atrial fibrillation after non-cardiothoracic surgery in the same way as for new-onset atrial fibrillation with any other cause.
Antithrombotic Therapy for Postoperative Atrial Fibrillation
- In the prophylaxis and management of postoperative atrial fibrillation, use appropriate antithrombotic therapy and correct identifiable causes (such as electrolyte imbalance or hypoxia).
References
References