Atrial fibrillation (AF)

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Lifetime risk 31%

Complications: CHF 42% Stroke 20% MI 10%

Questionnaire/history:

Suggestive symptoms?

Examination:

Pulse irregular?

Investigations:

ECG? Ambulatory ECG monitor? KardiaMobile? If AF confirmed: TSH, FBC, U&E, LFT If rhythm control strategy considered or suspicion of structural or functional heart disease (eg HF, valve disease): Echo

Management:

Anticoagulation: CHA2DS2-VASc score?

Score >= 2: Offer anticoagulation taking bleeding risk into account

Score = 1 in men consider anticoagulation taking bleeding risk into account

Score = 0 in men or <= 1 in women do not offer anticoagulation, but review again aged 65 or if develops diabetes or other cardiovascular comorbidities

DOAC (as first line choice (apixaban, rivaroxaban, edoxaban or dabigatran))

Mechanical heart vaIves & moderate-severe mitraI stenos? Warfarin

ORBIT score? (Focus is to identify those at higher risk and modify risk factors (e.g. uncontrolled hypertension, alcohol XS, drugs e.g. NSAIDs, consider PPI esp. in older people)

(For most people benefits of anticoagulation will outweigh the risks; age and fall risks are not contraindications to anticoagulation in their own right)

Rate control: First line for most people: Initial HR target <= 110 bpm, aiming for lower <= 80 bpm if ongoing symptoms (from the AF) 1st line: monotherapy with standard BB or rate-limiting CCB (diltiazem or verapamil, avoid if HF) 2nd line: dual therapy with 2 of BB/diltiazem/digoxin

Digoxin monotherapy: if sedentary or other rate-limiting options unsuitable due to co-morbidities

Rhythm control: May be more favourable if: younger age, 1st AF episode or short hx no/few co-morbidities or heart disease, rate control difficult to achieve, AF precipitated by temporary event (e.g. acute illness) Co-morbidity risk factor modification: Obesity, diabetes, lipids Tight BP control <= 130-80 (ESC) Decreased alcohol consumption Consider sleep apnoea and refer if suspected

Refer: Urgently: if acutely symptomatic and haemodynamic instability or decompensated heart failure Routinely: if suspected underlying structural or functional heart disease (eg HF, valve disease), rhythm control strategy being considered, ongoing symptoms despite 2nd line rate control drugs

Resource(s): NICE CKS: Atrial Fibrillation: diagnosis and management

ESC: 2024 ESC Guidelines for the management of atrial fibrillation