Atrial fibrillation

Red Flags

Haemodynamically unstable AF (hypotension, ischaemic chest pain, acute heart failure) — emergency electrical cardioversion^[1]
AF with rapid ventricular response and pre-excitation (e.g., WPW with delta wave) — avoid AV-nodal blockers (digoxin, verapamil, diltiazem); use procainamide or DC cardioversion^[1]
New ischaemic stroke or TIA in newly diagnosed AF — start oral anticoagulation per timing guidance once haemorrhage excluded^[1]
AF with valvular disease (moderate–severe mitral stenosis or mechanical valve) — DOACs contraindicated; warfarin only^[1]

First-line treatment

Interventions

Catheter ablation (pulmonary vein isolation)^[1]
Class I as first-line rhythm control in symptomatic paroxysmal AF in selected patients per 2024 update; class I in HFrEF with AF to improve outcomes
Comorbidity and risk-factor management (AF-CARE 'C')^[1]
Treat hypertension, sleep apnoea, obesity, diabetes, alcohol excess, and physical inactivity — central pillar of 2024 framework

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Apixaban^[1]	Direct oral anticoagulant (DOAC, factor Xa inhibitor)	5 mg PO BD; reduce to 2.5 mg BD if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL	—	Preferred over warfarin in non-valvular AF. CHA₂DS₂-VA ≥2 (men or women): anticoagulate; ≥1: consider
Dabigatran^[1]	Direct oral anticoagulant (DOAC, direct thrombin inhibitor)	150 mg PO BD; reduce to 110 mg BD if age ≥80, bleeding risk, or eGFR 30–49	—	Alternative DOAC; idarucizumab is the specific reversal agent
Rivaroxaban^[1]	Direct oral anticoagulant (DOAC, factor Xa inhibitor)	20 mg PO once daily with food; reduce to 15 mg once daily if eGFR 15–49	—	Once-daily dosing improves adherence
Warfarin^[1]	Vitamin K antagonist	Titrate to INR 2–3 (mechanical mitral valve: 2.5–3.5)	—	First-line in moderate–severe mitral stenosis or mechanical heart valves where DOACs are contraindicated
Bisoprolol^[1]	Beta-blocker (cardioselective)	2.5–10 mg PO once daily, titrate to resting HR <110 (lenient) or <80 (strict if symptomatic)	—	First-line rate control. Metoprolol succinate or carvedilol are interchangeable
Diltiazem^[1]	Non-DHP calcium channel blocker	120–360 mg PO daily (extended release)	—	Rate control alternative when beta-blockers contraindicated. AVOID in HFrEF
Amiodarone^[1]	Class III antiarrhythmic	Loading 600–800 mg/day for 1 week then 200 mg/day maintenance	—	Rhythm control in structural heart disease where flecainide and propafenone are contraindicated. Monitor TFTs, LFTs, CXR for pulmonary toxicity

Apixaban^[1]

Direct oral anticoagulant (DOAC, factor Xa inhibitor)

Adult: 5 mg PO BD; reduce to 2.5 mg BD if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL
Paediatric: —

Preferred over warfarin in non-valvular AF. CHA₂DS₂-VA ≥2 (men or women): anticoagulate; ≥1: consider

Dabigatran^[1]

Direct oral anticoagulant (DOAC, direct thrombin inhibitor)

Adult: 150 mg PO BD; reduce to 110 mg BD if age ≥80, bleeding risk, or eGFR 30–49
Paediatric: —

Alternative DOAC; idarucizumab is the specific reversal agent

Rivaroxaban^[1]

Direct oral anticoagulant (DOAC, factor Xa inhibitor)

Adult: 20 mg PO once daily with food; reduce to 15 mg once daily if eGFR 15–49
Paediatric: —

Once-daily dosing improves adherence

Warfarin^[1]

Vitamin K antagonist

Adult: Titrate to INR 2–3 (mechanical mitral valve: 2.5–3.5)
Paediatric: —

First-line in moderate–severe mitral stenosis or mechanical heart valves where DOACs are contraindicated

Bisoprolol^[1]

Beta-blocker (cardioselective)

Adult: 2.5–10 mg PO once daily, titrate to resting HR <110 (lenient) or <80 (strict if symptomatic)
Paediatric: —

First-line rate control. Metoprolol succinate or carvedilol are interchangeable

Diltiazem^[1]

Non-DHP calcium channel blocker

Adult: 120–360 mg PO daily (extended release)
Paediatric: —

Rate control alternative when beta-blockers contraindicated. AVOID in HFrEF

Amiodarone^[1]

Class III antiarrhythmic

Adult: Loading 600–800 mg/day for 1 week then 200 mg/day maintenance
Paediatric: —

Rhythm control in structural heart disease where flecainide and propafenone are contraindicated. Monitor TFTs, LFTs, CXR for pulmonary toxicity

Safety-net

Take anticoagulation every day at the same time — missing doses sharply raises stroke risk; never stop without medical advice^[1]
Sudden weakness on one side, slurred speech, severe headache, or vision changes — call emergency services immediately (possible stroke)^[1]
Watch for unusual bruising, prolonged bleeding, black stools, or bloody urine — contact your clinician promptly^[1]

Referral criteria

Haemodynamically unstable AF (hypotension, ischaemic chest pain, acute heart failure)Emergency department for synchronised electrical cardioversion^[1]
Symptomatic paroxysmal AF despite rate control or rhythm-control drug therapyCardiology / electrophysiology for catheter ablation evaluation^[1]
AF with new-onset heart failure or LVEF <50%Cardiology for early rhythm control and HF therapy^[1]
AF with high bleeding risk despite indication for anticoagulationCardiology / electrophysiology for left atrial appendage occlusion (LAAO) evaluation^[1]

Clinical summary

Diagnosis and management of atrial fibrillation, anchored on the AF-CARE framework: comorbidities, anticoagulation, reduce symptoms, evaluation.

References

1.2024 ESC Guidelines for the management of atrial fibrillation (developed with EACTS) (2024)