Symptoms (in order of increasing severity/urgency)

• Palpitation
• Dyspnoea
• Chest pain
• Dizziness
• Syncope
• Cardiac arrest

Signs

• Heart rate <60 or >100 beats/min
• Hypotension (systolic BP<100 mmHg)
• Hypoperfusion
• Jugular venous pressure (JVP) elevated
• Cannon waves or flutter waves in internal jugular vein
• Variable intensity of first heart sound
• Signs of heart failure

Investigations

• 12-lead ECG. A single-lead rhythm strip is an inferior alternative, but better than no ECG at all
• Urgent U&E

Important differential diagnosis

• Wolff-Parkinson-White (WPW) syndrome can present as AF. QRS complexes will be pre-excited (i.e. wide and bizarre), and ventricular response very fast with a tendency to degenerate to ventricular flutter and fibrillation (VF).

• never give digoxin or verapamil but seek urgent cardiology advice from on-call SpR with a view to restoring sinus rhythm with flecainide or sotalol, or with DC cardioversion

• If patient in peri-arrest situation, follow advanced life support - see Cardiopulmonary resuscitation - life support procedure guideline

• Consider thromboprophylaxis with DOAC or warfarin (maintenance INR 2.5) for ALL patients with sustained or paroxysmal AF or flutter depending on their CHA₂DS₂VASc  score

Choosing for the individual patient

• Weigh the risk of thromboembolic stroke against the adverse risk of bleeding
• Assess the risk of stroke, using the CHA₂DS₂VASc score
• Assess the risk of major bleeding from anticoagulation (a bleed requiring hospital admission, a blood transfusion or causing stroke) by the ORBIT score and other risk factors:
  • congestive heart failure (or LVEF <40%)
  • hypertension (ever, treated/untreated)
  • labile INR
  • alcohol abuse (≥ 8 drinks/week)
  • NSAIDs
• ORBIT scoring and other risk factors assess bleeding risk. High scores do not mean patients are contraindicated for anticoagulation but caution and closer monitoring is required

Antiplatelets

• If patient receiving antiplatelet therapies for coronary stent, do NOT discontinue, contact cardiology SpR

ORBIT

Making decision

• In considering whether to start DOAC or warfarin, discuss with patient and carers the risks and benefits and the need for regular therapy and, in the case of warfarin, INR checks
• If a decision is made not to anticoagulate the patient, document the reason in the notes

Chronic AF

• For rate control, prefer bisoprolol 2.5-10 mg/atenolol 50-100 mg oral daily or (if no LV systolic dysfunction/heart failure) consider calcium antagonist [verapamil 40-80 mg 8-hrly or diltiazem SR up to 300 mg/day (contact pharmacy for advice on dosing/brands)] 
• digoxin will control resting rate but not exercise rate
• For thromboembolic risk reduction, see ANTICOAGULATION above

Back in sinus rhythm

• If sinus rhythm restored after recurrent episode of AF with no obvious precipitant (e.g. pneumonia), consider long-term prophylactic therapy
• patients with evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy, or hypertensive disease, use a beta-blocker (e.g. bisoprolol/atenolol). If contraindicated, seek advice from on-call cardiologist SpR
• patients with no evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy, consider Class 1c agent (e.g. propafenone, flecainide) after seeking advice from on-call cardiology SpR

Unsuccessful cardioversion

• If DC or chemical cardioversion unsuccessful, consider long-term control of the ventricular response
• if heart failure present, use digoxin +/- beta-blocker or, if beta-blocker contraindicated, seek cardiology advice from on-call SpR on use of amiodarone
• if no heart failure present, use beta-blocker or, if beta-blocker contraindicated, diltiazem or verapamil

Bradycardia/tachycardia form of sino-atrial disease

• For prevention of AF in the bradycardia/tachycardia form of sino-atrial disease, consider pacing - seek advice from on-call cardiologist SpR 

Ablation therapy

• Consider ablation therapy. Refer patients to Electro-physiology consultant with:
• WPW syndrome (ALL patients)
• persistent AF in whom ventricular response cannot be satisfactorily controlled with drug therapy
• recurrent AF
• taking an anti-arrhythmic agent
• paroxysmal AF with symptoms

Alerts on drug combinations

• Avoid combinations of anti-arrhythmic drugs (including beta-blockers, diltiazem and verapamil) except after specific cardiological advice
• Avoid combinations of anti-arrhythmic drugs and diuretics if possible as hypokalaemia worsens pro-arrhythmic potential

• Do NOT discharge patient from hospital taking rhythm-controlling agents (unless advised to by a cardiologist) as these are unlikely to restore sinus rhythm and expose patient unnecessarily to risk of drug-induced arrhythmia

Follow-up

• If new onset AF, consider cardiology referral for DC cardioversion
• For any patient requiring on-going management of rate/rhythm not under current cardiology follow-up, refer to AF/arrhythmia nurse team
• Otherwise ask for GP review
• Request outpatient echocardiogram
• request follow-up clinician to refer to cardiologist if echocardiogram abnormal

Anticoagulation

• If taking DOAC, ask for GP review in 4 months for renal function/adherence
• If taking warfarin, follow guidance in yellow anticoagulation book