Atrial fibrillation: management – NICE guideline (update)

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This National Institute for Health and Care Excellence (NICE) guideline covers diagnosing and managing atrial fibrillation in adults. It aims to ensure that people receive the best management to help prevent harmful complications, in particular stroke and bleeding.

Key recommendations

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 in line with recommendation 1.3.1 in 'Venous thromboembolic diseases' (NICE clinical guideline 144)
    • support networks (for example, cardiovascular charities). [new 2014]

Referral for specialised management

Refer people promptly[1] at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed. [new 2014]

Assessment of stroke and bleeding risks

Stroke risk

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. [new 2014]

Bleeding risk

Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation. Offer modification and monitoring of the following risk factors:

  • uncontrolled hypertension
  • poor control of international normalised ratio (INR) ('labile INRs')
  • concurrent medication, for example concomitant use of aspirin or a non‑steroidal anti‑inflammatory drug (NSAID)
  • harmful alcohol consumption. [new 2014]

Interventions to prevent stroke

Anticoagulation

  • Anticoagulation may be with:
    • apixaban
    • dabigatran etexilate
    • rivaroxaban
    • a vitamin K antagonist.
  • Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account. [new 2014]

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

Antiplatelets

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

Rate and rhythm control

When to offer rate or rhythm control

Offer rate control as the first‑line strategy to people with 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. [new 2014]

Left atrial ablation and a pace and ablate strategy

Left atrial ablation

If drug treatment has failed to control symptoms of atrial fibrillation or is unsuitable:

  • offer left atrial catheter ablation to people with paroxysmal atrial fibrillation
  • consider left atrial catheter or surgical ablation for people with persistent atrial fibrillation
  • discuss the risks and benefits with the person[2]. [new 2014]

[1] The Guideline Development Group defined 'promptly' as no longer than 4 weeks after the final failed treatment or no longer than 4 weeks after recurrence of atrial fibrillation following cardioversion when further specialised management is needed.

[2] For more information on left atrial catheter ablation see Percutaneous balloon cryoablation for pulmonary vein isolation in atrial fibrillation (NICE interventional procedure guidance 427), Percutaneous endoscopic catheter laser balloon pulmonary vein isolation for atrial fibrillation (NICE interventional procedure guidance 399) and Percutaneous (non-thoracoscopic) epicardial catheter radiofrequency ablation for atrial fibrillation (NICE interventional procedure guidance 294). For more information on left atrial surgical ablation without thoracotomy see Thoracoscopic epicardial radiofrequency ablation for atrial fibrillation (NICE interventional procedure guidance 286).

Atrial fibrillation is the most common sustained cardiac arrhythmia, and estimates suggest its prevalence is increasing. If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and the prevalence increases with age.

The aim of treatment is to prevent complications, particularly stroke, and alleviate symptoms. Drug treatments include anticoagulants to reduce the risk of stroke and antiarrhythmics to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. Non‑pharmacological management includes electrical cardioversion, which may be used to 'shock' the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the abnormal electrical impulses that cause atrial fibrillation.

This updated guideline addresses several clinical areas in which new evidence has become available, including stroke and bleeding risk stratification, the role of new antithrombotic agents and ablation strategies.

The recommendations apply to adults (18 years or older) with atrial fibrillation, including paroxysmal (recurrent), persistent and permanent atrial fibrillation, and atrial flutter. They do not apply to people with congenital heart disease precipitating atrial fibrillation.

You can read the guideline on NICE's website.