Atrial Fibrillation

Patient Presentation:

• New cases of atrial fibrillation who are hemodynamically stable.
• Asymptomatic AF detected during routine review.
• AF with symptoms of palpitation or dyspnoea on exertion.

Confirm AF with ECG:

• Resting 12 lead ECG or rhythm strip ≥ 30 seconds from handheld device or smartwatch.

Assess Stroke Risk:

• Use CHA2DS2-VASc score to determine thromboembolism risk.

Heart Rate Control:

• Heart rate >110bpm without heart failure: Beta-blocker or calcium channel blocker (e.g., bisoprolol, atenolol, verapamil).
• Heart rate <110bpm and asymptomatic: No immediate anti-arrhythmic required; consider 24-hour tape to assess overall rate control.
• Heart rate >110bpm with heart failure: Consider digoxin or beta-blocker as appropriate, with reference to local guidelines.

Oral Anticoagulant Therapy:

• Initiate based on CHA2DS2-VASc score and patient discussion.
• For mechanical heart valves or moderate/severe mitral stenosis: Initiate Warfarin.

Lifestyle Advice:

• Encourage weight loss for overweight patients (BMI >27kg/m²).
• Encourage physical activity and moderate exercise.
• Discuss moderation or abstinence from alcohol.
• Advise minimising caffeine intake.

• Criteria for Rhythm Control and Cardioversion:
• Symptomatic AF despite adequate rate control.
• Young age (<65 years).
• Inadequate rate control despite measures or intolerance of these.
• Structural heart disease on echocardiography.
• AF and co-existing heart failure.
• Symptomatic paroxysmal AF requiring a rhythm control strategy.

• Controlled and Asymptomatic AF: Patients with controlled heart rates and no symptoms can be managed within primary care.
• Low CHA2DS2-VASc Score: Patients with a CHA2DS2-VASc score of 0 (♂) or 1 (♀) may not require immediate referral unless undergoing specific procedures like cardioversion or ablation.