CHA2DS2-VASc score 1for
women – 2 for men and HAS-
BLED score less than or equal
to 2 - anticoagulation treatment
indicated
JFC guidance
Atrial Fibrillation Pathway
This pathway has been developed from published guidance,
in collaboration with local cardiologists.
This guidance is to assist GPs in decision making and is not
intended to replace clinical judgment.
Symptomatic presentation of AF
Most common presenting symptoms-breathlessness, chest
pain, syncope/dizziness and palpitations also reduced
exercise tolerance, malaise and polyuria. May present with
associated complications- stroke, TIA, or heart failure
Often asymptomatic.
Pathway created by NCL
Approved by Clinical Cabinet
December 2017
Review due November 2020
Refer to Cardiology if
rate poorly controlled
or ongoing symptoms
Does the patient have any red flags?
Loss of consciousness
Acute significant breathlessness and/or light-headedness
Chest pain
TIA/ Stroke
Haemodynamic instability
Onset of symptoms <48 hrs?
AF diagnosis confirmed on 12 lead ECG?
Typical ECG - no p waves
Refer to Cardiology
DVLA Recommendations:
Advise the person that it is their responsibility to inform the
Driver and Vehicle Licensing Agency (DVLA) of any condition
that may affect their ability to drive.
The latest information from the DVLA regarding medical
fitness to drive can be obtained at https://www.gov.uk/
government/collections/assessing-fitness-to-drive-guide-for-
medical-professionals.
Comments & enquiries relating to medication:
CCCG Medicines Management Team mmt.camdenccg@nhs.net
Refer to current BNF or SPC for full medicines information
Clinical Contact for pathway queries: Camden.pathways@nhs.net
Opportunistic find of AF
Urgent/Emergency referral to
secondary care as appropriate
Yes
No
Palpitations
pathway
No
Yes
Discuss with duty
cardiologist
Yes
Assess stroke risk with CHA2DS2-VASc score CHA2DS2-VASc score 0
No
No antithrombotic/
antiplatelet therapy
Further Investigations
Bloods – FBC, U/E, LFT, TFT. Consider also Ca"+ Mg "+
24/48-hr/ 7-day ECG as appropriate if required to confirm
diagnosis
Echo (after rate controlled)
Consider also Ca2+, Mg2+ and HbA1c
Consider chest x-ray if suspected respiratory pathology
Consider Echo if high risk of underlying structural heart
disease
Exclude underlying causes or triggers:
- Cardiac causes, such as hypertension, valvular heart
disease, heart failure, and ischaemic heart disease.
- Respiratory causes, such as chest infections, pulmonary
embolism, and lung cancer.
- Systemic causes, such as excessive alcohol intake,
thyrotoxicosis, electrolyte depletion, infections, and
diabetes mellitus
ALERT:
If major bleed or
HAS-BLED score 3 . Do benefits
of anticoagulants outweigh the
risks of bleed?
HAS-BLED
score table
Rhythm Control (i.e. cardioversion)
Patients who are:
When pharmacological treatment has failed
Moderate to severe symptoms
<75 or by discretion
Presenting for the first time with lone AF
Secondary to a treated or corrected precipitant
With congestive heart failure
Suitable for AF ablation
Rate control in primary care (aim for rate control of 60-80 BPM)
(Best in elderly 75+, minimal symptoms, CHD)
Target heart rate <90bpm
Initial monotherapy beta blocker OR diltiazem
B blocker – e.g. Bisoprolol, 1.25mg titrated upwards max 10mg OD
Diltiazem 60mg tds –max 360mg OD (Verapamil 120-240mg
possible off-label alternative)
If poor rate control with single agent, combine B blocker + Diltiazem
+/- Digoxin). Seek specialist advice before prescribing diltiazem with
a beta-blocker
Digoxin monotherapy poor for rate control to be used in non-
paroxysmal AF and sedentary patients
Follow up 1 week later, assess:
Tolerance to treatment
Symptom control
HR, BP
Absence of an irregular pulse
makes a diagnosis of AF unlikely,
but its presence does not reliably
indicate AF
Reference
https://cks.nice.org.uk/atrial-fibrillation
Commence anticoagulation or refer as
apropriate (warfarin initiation- 20
care, DOAC initiation -10 care if trained
clinician and patient suitable)
Patient information leaflet
Also refer patients to www.atrialfibrillation.org.uk
Risk of stroke is 5 times higher in a person with AF
Anticoag treatment reduces risk of stroke by about
2/3
For most people the benefit of anticoag treatment
outweighs the risk of bleeding
NICE patient decision aid
