Initial assessment and diagnosis: Confirm atrial fibrillation (AF) by ECG showing absence of distinct repeating P waves and irregularly irregular R-R intervals, alongside clinical examination and assessment of symptoms, comorbidities, and possible underlying causes such as hypertension or valvular disease. Consider additional investigations like blood tests, chest X-ray, and transthoracic echocardiogram (TTE) depending on clinical judgement NICE CKS.
Stroke risk assessment and anticoagulation: Assess stroke and bleeding risk using clinical profiles and discuss anticoagulation options with the patient. Direct-acting oral anticoagulants (DOACs) are first-line unless contraindicated. Offer anticoagulation when benefits outweigh bleeding risk, with careful monitoring in higher-risk patients. Consider left atrial appendage occlusion only if anticoagulation is contraindicated or not tolerated NICE CKS,NICE NG196.
Rate control: Offer rate control as the first-line treatment in most cases unless rhythm control is preferred due to reversible cause, heart failure caused primarily by AF, or new-onset AF. Initial rate control is with either a beta-blocker (excluding sotalol) or a rate-limiting calcium-channel blocker (diltiazem or verapamil), chosen based on symptoms, heart rate, comorbidities, and patient choice. For patients with heart failure, avoid calcium-channel blockers and use beta-blockers. Digoxin monotherapy may be considered if the patient is sedentary or other options are unsuitable. Combination therapy (two of beta-blocker, diltiazem, digoxin) can be used if monotherapy is insufficient NICE NG196.
Rhythm control: Consider rhythm control strategies in patients with symptomatic AF despite adequate rate control, new-onset AF, or patient preference. Cardioversion is electrical preferred over pharmacological if AF duration exceeds 48 hours. Amiodarone may be used before and up to 12 months after cardioversion to maintain sinus rhythm. For paroxysmal AF with infrequent symptoms, a "pill-in-the-pocket" approach using flecainide or amiodarone may be considered if no structural heart disease is present. For persistent or symptomatic AF unresponsive or unsuitable for drug therapy, consider left atrial ablation techniques after discussing risks, benefits, and patient preferences NICE CKS,NICE NG196.
Acute management: In new-onset or acute AF without life-threatening instability, offer rate or rhythm control based on timing (<48 hours rhythm control) and clinical context. In haemodynamically unstable patients, emergency electrical cardioversion should be performed immediately NICE NG196.
Ongoing management and review: Regularly reassess symptoms, stroke and bleeding risks, and treatment effectiveness. Monitor adherence and adverse effects of drugs. Refer promptly for specialist cardiology input if symptoms persist despite optimal treatment or if advanced interventions are needed NICE CKS,NICE NG196.
Patient education and support: Provide personalised care including stroke awareness, anticoagulation education, symptom management, and information on support networks. Shared decision-making is essential in all management decisions NICE NG196.