People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Perform manual pulse palpation to assess for the presence of an irregular pulse if there is a suspicion of atrial fibrillation. This includes people presenting with any of the following:
Perform a 12‑lead electrocardiogram (ECG) to make a diagnosis of atrial fibrillation if an irregular pulse is detected in people with suspected atrial fibrillation with or without symptoms. [2021]
In people with suspected paroxysmal atrial fibrillation undetected by 12‑lead ECG recording:
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on detection and diagnosis.
Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on stroke risk.
Assess the risk of bleeding when:
Offer monitoring and support to modify risk factors for bleeding, including:
Discuss the results of the assessments of stroke and bleeding risk with the person taking into account their specific characteristics, for example comorbidities, and their individual preferences. For further guidance, see the section on enabling patients to actively participate in their care in NICE's guideline on patient experience in adult NHS services. [2021]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on bleeding risk.
Perform transthoracic echocardiography (TTE) in people with atrial fibrillation:
Do not routinely perform TTE solely for the purpose of further stroke risk stratification in people with atrial fibrillation for whom the need to start anticoagulation therapy has already been agreed on appropriate clinical criteria (see section 1.2 on assessment of stroke and bleeding risks and section 1.6 on stroke prevention). [2006, amended 2014]
Perform transoesophageal echocardiography (TOE) in people with atrial fibrillation:
Offer people with atrial fibrillation a personalised package of care. Ensure that the package of care is documented and delivered, and that it covers:
To support adherence and ensure safe and effective medicines use in people with atrial fibrillation, follow the recommendations in NICE's guidelines on medicines adherence and medicines optimisation. [2021]
Refer people promptly at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed. This should be within 4 weeks after the failed treatment or after recurrence of atrial fibrillation after cardioversion. [2014]
When discussing the benefits and risks of anticoagulation use clinical risk profiles and personal preferences to guide treatment choices. Discuss with the person that:
When deciding between anticoagulation treatment options:
Offer anticoagulation with a direct‑acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2‑VASc score of 2 or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (see the section on direct-acting oral anticoagulant treatment options). [2021]
Consider anticoagulation with a direct‑acting oral anticoagulant for men with atrial fibrillation and a CHA2DS2‑VASc score of 1, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (see the section on direct-acting oral anticoagulant treatment options). [2021]
If direct‑acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist. See the section on self-monitoring and self-management of vitamin K antagonists. [2021]
For adults with atrial fibrillation who are already taking a vitamin K antagonist and are stable, continue with their current medication and discuss the option of switching treatment at their next routine appointment, taking into account the person's time in therapeutic range. [2021]
Do not offer stroke prevention therapy with anticoagulation to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2‑VASc score of 0 for men or 1 for women). [2021]
Do not withhold anticoagulation solely because of a person's age or their risk of falls. [2021]
These options are listed in alphabetical order.
TA275: Apixaban
Apixaban is recommended as an option for preventing stroke and systemic embolism within its marketing authorisation, that is, in people with non-valvular atrial fibrillation with 1 or more risk factors such as:
Decide whether to start treatment with apixaban after an informed discussion with the person about its risks and benefits compared with warfarin, dabigatran etexilate, edoxaban and rivaroxaban. For people taking warfarin, consider the potential risks and benefits of switching to apixaban taking into account their level of international normalised ratio (INR) control.
TA249: Dabigatran etexilate
Dabigatran etexilate is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with nonvalvular atrial fibrillation with one or more of the following risk factors:
Decide whether to start treatment with dabigatran etexilate after an informed discussion with the person about its risks and benefits compared with warfarin, apixaban, edoxaban and rivaroxaban. For people taking warfarin, consider the potential risks and benefits of switching to dabigatran etexilate taking into account their level of international normalised ratio (INR) control.
TA355: Edoxaban
Edoxaban is recommended, within its marketing authorisation, as an option for preventing stroke and systemic embolism in adults with non-valvular atrial fibrillation with one or more risk factors, including:
Decide whether to start treatment with edoxaban after an informed discussion with the person about its risks and benefits compared with warfarin, apixaban, dabigatran etexilate and rivaroxaban. For people taking warfarin, consider the potential risks and benefits of switching to edoxaban taking into account their level of international normalised ratio (INR) control.
TA256: Rivaroxaban
Rivaroxaban is recommended as an option for the prevention of stroke and systemic embolism within its licensed indication, that is, in people with non-valvular atrial fibrillation with one or more risk factors such as:
Decide whether to start treatment with rivaroxaban after an informed discussion with the person about its risks and benefits compared with warfarin, apixaban, dabigatran etexilate and edoxaban. For people taking warfarin, consider the potential risks and benefits of switching to rivaroxaban taking into account their level of international normalised ratio (INR) control.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on stroke prevention.
Calculate the person's time in therapeutic range (TTR) at each visit. When calculating TTR:
Reassess anticoagulation for a person whose anticoagulation is poorly controlled shown by any of the following:
When reassessing anticoagulation, take into account and if possible address the following factors that may contribute to poor anticoagulation control:
If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person. [2014]
For guidance on antiplatelet therapy for people who have had a myocardial infarction and are having anticoagulation, see antiplatelet therapy for people with an ongoing separate indication for anticoagulation in NICE's guideline on acute coronary syndromes.
Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation. [2014]
For people who are not taking an anticoagulant, review stroke risk when they reach age 65 or if they develop any of the following at any age:
For people who are not taking an anticoagulant because of bleeding risk or other factors, review stroke and bleeding risks annually, and ensure that all reviews and decisions are documented. [2014]
For people who are taking an anticoagulant, review the need for anticoagulation and the quality of anticoagulation (taking into account MHRA advice on direct-acting oral anticoagulants about bleeding risk and the need to monitor renal function in patients with renal impairment) at least annually, or more frequently if clinically relevant events occur affecting anticoagulation or bleeding risk. [2014]
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. [2014]
Do not offer LAAO as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated. [2014]
This section covers rate and rhythm control in non‑acute settings. See section 1.8 for rate and rhythm control for people presenting acutely (either new onset or destabilisation of existing atrial fibrillation).
Offer rate control as the first‑line treatment strategy for atrial fibrillation except in people:
Offer either a standard beta‑blocker (that is, a beta‑blocker other than sotalol) or a rate‑limiting calcium‑channel blocker (diltiazem or verapamil) as initial rate‑control monotherapy to people with atrial fibrillation unless the person has the features described in recommendation 1.7.4. Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences. [2021]
In April 2021, this was an off‑label use of diltiazem. See NICE's information on prescribing medicines.
Consider digoxin monotherapy for initial rate control for people with non‑paroxysmal atrial fibrillation if:
If monotherapy does not control the person's symptoms, and if continuing symptoms are thought to be caused by poor ventricular rate control, consider combination therapy with any 2 of the following:
Do not offer amiodarone for long-term rate control. [2021]
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on rate control.
Full details of the evidence and the committee's discussion are in evidence review I: non-ablative rate control therapies.
Consider pharmacological and/or electrical rhythm control for people with atrial fibrillation whose symptoms continue after heart rate has been controlled or for whom a rate‑control strategy has not been successful. [2014]
Assess the need for drug treatment for long‑term rhythm control, taking into account the person's preferences, associated comorbidities, risks of treatment and likelihood of recurrence of atrial fibrillation. [2014]
Do not offer class 1c antiarrhythmic drugs such as flecainide or propafenone to people with known ischaemic or structural heart disease. [2014]
If drug treatment for long‑term rhythm control is needed, consider a standard beta‑blocker (that is, a beta‑blocker other than sotalol) as first‑line treatment unless there are contraindications. [2014]
If beta‑blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control, taking comorbidities into account. [2014]
Follow the advice on dronedarone as a second-line treatment option for long-term rhythm control after successful cardioversion (TA197). [2014]
TA197: Dronedarone
Dronedarone is recommended as an option for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation:
People who do not meet these criteria who are currently having dronedarone should have the option to continue treatment until they and their clinicians consider it appropriate to stop.
Consider amiodarone for people with left ventricular impairment or heart failure. [2014]
In people with infrequent paroxysms and few symptoms, or if symptoms are induced by known precipitants (such as alcohol, caffeine), a 'no drug treatment' strategy or a 'pill-in-the-pocket' strategy (in which antiarrhythmic drugs are taken only when an episode starts) should be considered and discussed with the person. [2006]
In people with paroxysmal atrial fibrillation, a 'pill‑in‑the‑pocket' strategy should be considered for those who:
For people having cardioversion for atrial fibrillation that has persisted for longer than 48 hours, offer electrical (rather than pharmacological) cardioversion. [2014]
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. [2014]
For people with atrial fibrillation of greater than 48 hours' duration, in whom elective cardioversion is indicated:
If drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic paroxysmal or persistent atrial fibrillation:
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. [2021]
Consider left atrial surgical ablation at the same time as other cardiothoracic surgery for people with symptomatic atrial fibrillation. [2014]
For NICE interventional procedures guidance on left atrial ablation for atrial fibrillation, see the NICE interventional procedures guidance on our topic page on heart rhythm conditions.
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on left atrial ablation.
Consider antiarrhythmic drug treatment for 3 months after left atrial ablation to prevent recurrence of atrial fibrillation, taking into account the person's preferences, and the risks and potential benefits. [2021]
Reassess the need for antiarrhythmic drug treatment at 3 months after left atrial ablation. [2021]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preventing recurrence after ablation.
Full details of the evidence and the committee's discussion are in evidence review K: antiarrhythmic drugs after ablation.
Consider pacing and atrioventricular node ablation for people with permanent atrial fibrillation with symptoms or left ventricular dysfunction thought to be caused by high ventricular rates. [2014]
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. [2014]
Consider left atrial catheter ablation before pacing and atrioventricular node ablation for people with paroxysmal atrial fibrillation or heart failure caused by non‑permanent (paroxysmal or persistent) atrial fibrillation. [2014]
Carry out emergency electrical cardioversion, without delaying to achieve anticoagulation, in people with life‑threatening haemodynamic instability caused by new‑onset atrial fibrillation. [2014]
In people with atrial fibrillation presenting acutely without life-threatening haemodynamic instability:
In people with atrial fibrillation 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. [2021]
Consider either pharmacological or electrical cardioversion depending on clinical circumstances and resources in people with new‑onset atrial fibrillation who will be treated with a rhythm‑control strategy. [2014]
If pharmacological cardioversion has been agreed on clinical and resource grounds for new‑onset atrial fibrillation, offer:
In people with atrial fibrillation 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. [2006, amended 2014]
Do not offer magnesium or a calcium‑channel blocker for pharmacological cardioversion. [2014]
For a short explanation of why the committee made the 2021 recommendation and how it might affect practice, see the rationale and impact section on rate and rhythm control for people presenting acutely.
Full details of the evidence and the committee's discussion are in evidence review I: non-ablative rate control therapies.
In people with new‑onset atrial fibrillation who are receiving no, or subtherapeutic, anticoagulation therapy:
In people with a confirmed diagnosis of atrial fibrillation of recent onset (less than 48 hours since onset), offer oral anticoagulation if:
In people with new‑onset atrial fibrillation, if there is uncertainty over the precise time since onset, offer oral anticoagulation as for persistent atrial fibrillation (see section 1.2 on assessment of stroke and bleeding risks and section 1.6 stroke prevention). [2006, amended 2014]
For guidance on the initial management of stroke and atrial fibrillation see recommendation 1.4.17 in NICE's guideline on stroke and transient ischaemic attack in over 16s. [2014]
In people having cardiothoracic surgery:
In people having cardiothoracic surgery who are already on beta‑blocker therapy, continue this treatment unless contraindications develop (such as postoperative bradycardia or hypotension). [2006, amended 2014]
Do not start statins in people having cardiothoracic surgery solely to prevent postoperative atrial fibrillation. [2021]
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. [2021]
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on preventing postoperative atrial fibrillation.
Consider either a rhythm‑control or rate‑control strategy for the initial treatment of new‑onset postoperative atrial fibrillation after cardiothoracic surgery. [2021]
If a rhythm‑control strategy is chosen, reassess the need for antiarrhythmic drug treatment at a suitable time point (usually at around 6 weeks). [2021]
Manage postoperative atrial fibrillation after non‑cardiothoracic surgery in the same way as for new-onset atrial fibrillation with any other cause. [2006, amended 2014]
In the prophylaxis and management of postoperative atrial fibrillation, use appropriate antithrombotic therapy and correct identifiable causes (such as electrolyte imbalance or hypoxia). [2006, amended 2014]
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on managing atrial fibrillation after cardiothoracic surgery.
In people with a diagnosis of atrial fibrillation, do not stop anticoagulation solely because atrial fibrillation is no longer detectable. [2021]
Base decisions to stop anticoagulation on a reassessment of stroke and bleeding risk using CHA2DS2‑VASc and ORBIT and a discussion of the person's preferences. [2021]
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on stopping anticoagulation.
This section defines terms that have been used in a particular way for this guideline.
People presenting with atrial fibrillation of definite recent onset or with destabilisation of existing atrial fibrillation. This does not include people with atrial fibrillation that has been discovered incidentally, for example through pulse palpitation before routine blood pressure measurement.
The person self‑manages paroxysmal atrial fibrillation by taking antiarrhythmic drugs only when an episode of atrial fibrillation starts.
Episodes of atrial fibrillation that stop within 7 days, usually within 48 hours, without any treatment.