atrial fibrillation screening in adults

If atrial fibrillation (AF) is suspected, perform manual pulse palpation to check for an irregular pulse. This is indicated for patients presenting with symptoms such as breathlessness, palpitations, syncope or dizziness, chest discomfort, or a history of stroke or transient ischaemic attack (TIA) ¹.

If an irregular pulse is detected, a 12-lead electrocardiogram (ECG) should be performed to confirm the diagnosis of AF. For suspected paroxysmal AF that is not detected by a standard 12-lead ECG, consider using a 24-hour ambulatory ECG monitor if asymptomatic episodes are suspected or symptomatic episodes occur less than 24 hours apart. If symptomatic episodes are more than 24 hours apart, use an ambulatory ECG monitor, event recorder, or other ECG technology for an appropriate duration to detect AF ¹.

Once AF is diagnosed, assess stroke risk using the CHA₂DS₂-VASc score for patients with paroxysmal, persistent, or permanent AF, or atrial flutter. Also, use this score for those at continuing risk of arrhythmia recurrence after cardioversion or catheter ablation ¹. Assess bleeding risk using the ORBIT bleeding risk score, especially when considering or reviewing anticoagulation therapy ¹. Discuss the results of these risk assessments with the patient, considering their individual characteristics and preferences ¹.

Offer patients with AF a personalised care package, including education on AF, its management, stroke prevention, and psychological support if needed. Ensure adherence and safe use of medications by following NICE guidelines on medicines adherence and optimisation ¹.

For stroke prevention, discuss the benefits and risks of anticoagulation with the patient, guiding treatment choices based on clinical risk profiles and personal preferences. For most patients, the benefits of anticoagulation outweigh the bleeding risk, but careful monitoring is essential for those at increased risk of bleeding ¹.

If drug treatment for symptomatic paroxysmal or persistent AF is unsuccessful, unsuitable, or not tolerated, consider left atrial ablation (radiofrequency, cryoballoon, or laser balloon ablation). Discuss the risks, benefits, and potential for symptom recurrence with the patient ¹. Consider left atrial surgical ablation during other cardiothoracic surgery if indicated ¹.

For AF persisting longer than 48 hours, offer electrical cardioversion over pharmacological cardioversion. Consider amiodarone therapy before and after electrical cardioversion to maintain sinus rhythm, after discussing its benefits and risks ¹. For AF of greater than 48 hours' duration where elective cardioversion is indicated, both transoesophageal echocardiography (TOE)-guided and conventional cardioversion can be considered equally effective. TOE-guided cardioversion may be considered if experienced staff and facilities are available, or if minimal precardioversion anticoagulation is needed ¹.

Mobile photoplethysmographic technology has been explored for detecting AF [ (Y et al., 2019)].