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.