Atrial fibrillation: diagnosis and management

Context

Atrial fibrillation is the most common heart rhythm disorder (affecting approximately 2% of the adult population), and estimates suggest its prevalence is increasing. Atrial fibrillation causes palpitations and breathlessness in many people but it may be silent and undetected. If left untreated it is a significant risk factor for stroke and other morbidities: it is estimated that it is responsible for approximately 20% of all strokes and is associated with increased mortality. Men are more commonly affected than women and the prevalence increases with age and in underlying heart disease, diabetes, obesity and hypertension.

Atrial fibrillation is typically detected as an irregular pulse or an irregular rhythm on an electrocardiogram (ECG). This may be an incidental finding or may arise while investigating symptoms suggestive of the disease. Because atrial fibrillation can be intermittent, detection and diagnosis may be challenging.

The aim of treatment is to prevent complications, particularly stroke, and alleviate symptoms. Drug treatments include anticoagulants to reduce the risk of stroke and antiarrhythmics to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. Non‑pharmacological management includes electrical cardioversion, which may be used to 'shock' the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the triggers that cause atrial fibrillation. These procedures can markedly reduce the symptom burden when drug therapy is ineffective or not tolerated.

This update focuses on areas of new evidence and changing practice since the 2014 NICE guideline. These include methods of identifying atrial fibrillation; assessing stroke and bleeding risk; antithrombotic agents; ablation strategies; preventing recurrence; and preventing and managing postoperative atrial fibrillation. This guideline update includes recommendations on these specific issues.

The recommendations apply to adults (18 years or older) with atrial fibrillation, including paroxysmal (recurrent), persistent and permanent atrial fibrillation, and atrial flutter. They do not apply to people with congenital heart disease precipitating atrial fibrillation.