NICE guideline recommends that GPs should adopt a patient-centred approach when managing and treating individual cases of AF, says Dr Alan Begg

Up to 1% of the population are affected by atrial fibrillation (AF), making it the most common arrhythmia seen in primary care. For those with the condition, there is a 5% chance of having a stroke.1

It is, therefore, important that NICE has published an evidence-based guideline on the early recognition and treatment by GPs and other healthcare professionals of this common condition.2 The guideline was produced in conjunction with the National Collaborating Centre for Chronic Conditions at the Royal College of Physicians. The evidence was considered using the standard NICE grading system (Figure 1).

Figure 1: Classification of recommendations on interventions

Reproduced by kind permission of the National Institute for Health and Care Excellence

The guideline covers all types of AF (Table 1) and also gives recommendations on when referral should be made to specialist services, e.g. if pharmacological therapy has failed (B), if there is lone AF (B) or when there is electrocardiogram (ECG) evidence of an electrophysiological disorder (C).

Table 1: Types of atrial fibrillation (AF)
Persistent AF

Lasts >7 days
Not self-terminating and requires pharmacological or electrical cardioversion

Permanent (accepted) AF Longstanding – usually longer than 1 year
Patient not suitable for cardioversion or it was unsuccessful
Paroxysmal AF Comes and goes – usually stops without treatment in <7 days and most often in <48 hours
Acute-onset AF Episode that started suddenly or worsened existing symptoms
Occurs in those with persistent or paroxysmal AF
Post-operative AF Occurs mainly after cardiothoracic surgery
Table 2: Risk factors for developing AF
Cardiac Coronary heart disease
Rheumatic heart disease
Non-cardiac Acute infection, especially pneumonia
Lung cancer
Pulmonary embolism
Post-surgical Thoracotomy
Coronary artery bypass graft
Dietary and lifestyle Excessive alcohol consumption
Caffeine intake
Emotional or physical stress

Identification of AF

Advancing age is a major risk factor for AF – the prevalence doubles with each decade,3 and 10% of people over the age of 75 years are affected.4 Other risk factors for developing AF are detailed in Table 2. It is recommended that manual pulse palpation should be an initial screen for any patient presenting with:

  • shortness of breath (breathlessness)/ dyspnoea
  • palpitations
  • fainting (syncope) or dizziness
  • chest pain or discomfort (chest discomfort)
  • symptoms of a stroke or transient ischaemic attack (TIA).

Confirming the diagnosis

An ECG should be performed in all patients where an irregular pulse is suspected (B). Computer-assisted ECG interpretation is becoming more available within general practice, but the advice from the British Heart Foundation remains that the computer diagnosis needs to be considered in the clinical context and after visual examination of the trace.5

A recent study looking at GP interpretation and identification of abnormal ECGs revealed differences in the ECG reporting skills between GPs. The authors concluded that there was, without doubt, a need for general practitioner training in ECG interpretation.6

Further investigations

A 24-hour ambulatory ECG should be performed in those suspected of having episodes of AF occurring less than 24 hours apart, and an event recorder ECG should be used in those whose events happen more than 24 hours apart (B).

An echocardiogram is recommended in:

  • younger patients as a baseline for long-term management (D[GPP])
  • those being considered for a rhythm-control strategy (C)
  • those with suspected valvular disease or heart failure (D[GPP])
  • assisting risk stratification for antithrombotic therapy (C).

Patient-centred care

The guideline indicates that treatment should take into account the patient's individual needs and preferences.2 This should involve good communication at all times and the information provided should be evidenced-based but tailored to the needs of each individual patient.

When appropriate, carers and relatives should be involved in any decisions about the management of AF.

Rate vs rhythm control

The initial management decision is whether the patient would benefit from a rate- or a rhythm-control strategy (Figure 2). For those with persistent AF, a rate-controlled strategy should be the preferred initial option for those:

  • aged over 65 years (B)
  • with coronary artery disease (B)
  • with contraindications to antiarrhythmic drugs (D[GPP])
  • unsuitable for cardioversion (D[GPP])
  • without congestive cardiac failure (B).

Figure 2: Treatment strategy decision tree

Reproduced by kind permission of the National Institute for Health and Care Excellence

A rhythm-control strategy should be considered in those:

  • who are symptomatic (D[GPP])
  • aged less than 65 years (C)
  • presenting with lone AF for the first time (D[GPP])
  • with AF due to a treatable or correctable condition (D[GPP])
  • with congestive heart failure (C).

Rhythm control consists of electrical cardioversion followed by an antiarrhythmic drug as indicated to maintain sinus rhythm, or pharmacological cardioversion using an intravenous antiarrhythmic agent.

Beta-blockers or rate-limiting calcium channel blockers are the preferred initial monotherapy for rate control if the patient is in permanent AF (A), with digoxin only being considered as monotherapy in sedentary patients (D[GPP]).

If monotherapy is inadequate, digoxin should be added to the initial therapy, but for those who are more active it should be combined with a rate-limiting calcium channel blocker (B).

'Pill-in-the-pocket' for paroxysmal AF

The guideline promotes this 'pill-in-the-pocket' approach, which involves self-administering an antiarrhythmic drug at the onset of an episode of AF.

It is suitable for those patients not taking drugs regularly due to infrequent symptoms/paroxysms or to be taken as an additional drug dose for those already on a maintenance dose of that particular drug.

This approach is only used in patients with no structural heart disease, and without heart failure or left ventricular failure, and where there is evidence that this approach has been successful previously, with no side-effects (C).

The antiarrhythmic drugs considered are amiodarone and propafenone, and the NICE AF guideline development group found evidence, albeit limited, that this approach was associated with less hospital admissions than conventional treatment2

Antithrombotic therapy

The decision on whether to give antithrombotic therapy to patients with permanent AF should be based on a risk:benefit assessment (see Figure 3) and must be discussed fully with the patient (D[GPP]). The decision on the need for antithrombotic therapy in patients with paroxysmal AF is similarly based on this risk stratification and not on the frequency or duration of paroxysms,whether symptomatic or not (B).

Figure 3: Stroke risk stratification algorithm

1. Note that risk factors are not mutually exclusive, and are additive to each other in producing a composite risk.
Since the incidence of stroke and thromboembolic events in patients with thyrotoxicosis appears similar to that in patients with other aetiologies of AF, antithrombotic treatments should be chosen based on the presence of validated stroke risk factors
2. Owing to lack of sufficient clear-cut evidence, treatment may be decided on an individual basis, and the physician must balance the risk and benefits of warfarin versus aspirin. As stroke risk factors are cumulative, warfarin may, for example, be used in the presence of two or more moderate stroke risk factors. Referral and echocardiography may help in cases of uncertainty.
*Coronary artery disease or peripheral artery disease.

** An echocardiogram is not needed for routine assessment, but refines clinical risk stratification in the case of moderate or severe LV dysfunction and valve disease.

Reproduced by kind permission of the National Institute for Health and Care Excellence

Although aspirin is inexpensive, patient friendly and relatively safe, in AF it has been shown to be less beneficial than warfarin in preventing a stroke7

The evidence for the use of anticoagulation as opposed to antiplatelet therapy has increased by the publication of the ACTIVE W trial8 This revealed that warfarin was superior to the combination of clopidogrel and aspirin in the prevention of vascular events (3.9% had vascular events per year on warfarin, and 5.6% on combination antiplatelet therapy) in patients with AF and at high risk of a stroke.

Interestingly, the benefits were greater in those on warfarin at study entry suggesting the possibility of a bias in favour of the treatment with greatest previous exposure.

Bleeding risk assessment

The decision on whether to commence anticoagulation in primary care remains difficult; but as the evidence increases in favour of the use of warfarin that decision may become easier.

The guideline suggests that the following should be considered before commencing the patient on anticoagulation therapy:

  • age if over 75 years (B)
  • if patient is on other anti-platelet drugs (aspirin or clopidogrel); nonsteroidal anti-inflammatory drugs or multiple other drug regimens (C)
  • presence of uncontrolled hypertension (C)
  • a previous history of bleeding, such as peptic ulcer or cerebral haemorrhage (C)
  • previous history of poorly controlled anticoagulation therapy (D[GPP]).


Atrial fibrillation has been included as a new clinical domain in QOF2, with a total of 30 points available for setting up a register, confirming the diagnosis and ensuring that, where appropriate, antithrombotic therapy has been prescribed.9The publication of this NICE guideline is timely and it will be a useful tool for practice teams who are in the process of developing their own evidence-based care pathway for the management of their AF patients.

Guidelines in Practice, July 2006, Volume 9(7)
© 2006 MGP Ltd
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  1. Department of Health. National Service Framework for Coronary Heart Disease – modern standards and service model. Chapter 8: Arrhythmias and Sudden Cardiac Death. London: DH, 2005.
  2. National Institute for Health and Care Excellence.Atrial fibrillation:The management of atrial fibrillation. NICE Clinical Guideline 36. London: NICE, 2006.
  3. Kannel W,Wolf P, Benjamin E, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 1998; 82 (8A): 2N-9N.
  4. Kirby M. Atrial fibrillation: strategies in primary care. Br J Cardiol 2005; 12 (4): 308-11.
  5. British Heart Foundation. Computer-Assisted ECG Interpretation. British Heart Foundation Factfile,
  6. Jeyaseelan S, Struthers A, Goudie B et al. The accuracy of ECG screening by GPs and by machine interpretation in selecting suspected heart failure patients for echocardiography. Br J Cardiol 2006; 13 (3) : 216-18.
  7. Lip G, Boos C.Antithrombotic treatment in atrial fibrillation.Heart 2006; 92 (2): 155-61.
  8. ACTIVE Writing Group on behalf of the ACTIVE Investigators; Connolly S, Pogue J, Hart R et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006; 367 (9526): 1903-12.
  9. British Medical Association. Revisions to the GMS contract 2006-2007: Delivering investment in general practice. London: BMA, 2006.