Diagnosis

• Manual pulse palpation in patients with:
  • SOB
  • Palpitations
  • Syncope / dizziness
  • Chest discomfort
  • Stroke / TIA
• Stroke risk: CHA2DS2VASc if AF (symptomatic or not, paroxysmal or persitent, atrial flutter, or risk of arrhythmia recurrence) note for most people benefit of anti-coagulation outweighs bleeding risk, unless increased risk of bleed
• Bleeding risk once started anti-coagulation: HAS-BLED. Offer to modify hypertensive risk, poor control of INR, concurrent NSAID, excessive alcohol consumption

Investigation

• ECG: If detect irregularly irregular pulse
• If paroxysmal AF suspected then ambulatory 24 hr ECG monitor if asymptomatic episodes or symptomatic < 24 hrs apart
• Transthoracic echo (TTE) in AF:
  • Baseline important
  • Rhythm control requiring cardioversion (Pharmacological or electrical)
  • Suspicion of underlying structural / functional heart disease influencing management
  • Refinement of risk stratification for anti-thrombotic therapy (NOT if already agreed initiation)
• Transoesophageal echo (TOE) in AF, when TTE demonstrates an abnormality i.e. valvular disease or where TTE is technically difficult
• Personalised care plan: stroke awareness; rate and rhythm control; anti-coagulation

Management

• Anti-coagulation: if CHADSVASc > 2 in both sexes or > 1 in men
  • Stroke (2)
  • Age > 75 (2)
  • Diabetes (1)
  • Cardiac Failure (1)
  • Hypertension (1)
  • Age > 65 (1)
  • Vascular Hx (1)
  • Sex (female) (1)
• New Anti-platelet: Apixaban, Dabigatran Rivaroxiban can be considered instead of Warfarin
• Vitamin K antagonist: assess Time in Therapeutic Range
• Reassess control if 2 INR > 5.0 or 1 > 8.0 OR 2 INR < 1.5, TTR < 65 %, addressing non adherence
• Do not offer Aspirin monotherapy for stroke prevention
• Review stoke risk of patients not taking an anti-coagulant when reach 65 or develop DM, HF, PAD, CHD, TIA

Chronic AF (assuming anti-coagulated as necessary)

• Rate Control in first instance unless:
• AF has reversible cause
• Heart failure caused by AF
• New onset AF
• Atrial flutter that could benefit from ablation
• Rhythm control preferred in clinical judgement

Rate Control: Beta Blocker or rate controlling CCB (Diltiazem)

• Digoxin: only if non paroxysmal and sedentary patient

If monotherapy does not control symptoms and poor ventricular rate control then any two of: Beta Blocker; Diltiazem; Digoxin

Rhythm Control: consider if heart rate is not controlled with rate controlling steps

• If > 48 hrs offer electrical cardioversion (with amiodarone 4 wks before and 12 weeks after)
• TOE Cardioversion should be offered alongside conventional cardioversion, equally effective
• Drug treatment for long term rhythm control consider standard Beta Blocker i.e. all except Sotolol
• Dronedarone recommended for maintenance of sinus rhythm after cardioversion
• Amidarone if LVF or HF
• ‘Pill in pocket’ for paroxysmal AF if no LVF, Valvular pathology of IHD (single dose anti-arhythmic)
• Left Atrial ablation: Catheter if paroxysmal or Surgical if symptomatic
• Pace and ablate if permanent symptomatic AF

Acute AF

• If life threatening then electrically cardiovert without waiting for anti-coagulation
• If non- life threatening and < 48 hr (ie not long enough for clot formation) can offer rhythm or rate control
• If > 48 hrs rate control only
• Type of cardioversion (drug or electrical) dependent on resources available
• If pharmacological then consider Flecanide (if no IHD) or Amiodarone
• Anti-coagulate with heparin until full assessment made OR Warfarin if unlikely to regain sinus rhythm

NICE Source: CG180 Atrial fibrillation: management. Summary compiled by Dr D P Sheppard MBBS.