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National Collaborating Centre for Chronic Conditions (UK). Atrial Fibrillation: National Clinical Guideline for Management in Primary and Secondary Care. London: Royal College of Physicians (UK); 2006. (NICE Clinical Guidelines, No. 36.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

3Key messages of the guideline

3.1. Priorities for implementation

The following five recommendations have been identified by the GDG as priorities for implementation:

  1. An electrocardiogram (ECG) should be performed in all patients, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected.
  2. As some patients with persistent AF will satisfy criteria for either an initial rate-control or rhythm-control strategy (for example, aged over 65 but also symptomatic):
    • the indications for each option should not be regarded as mutually exclusive and the potential advantages and disadvantages of each strategy should be explained to patients before agreeing which to adopt
    • any comorbidities that might indicate one approach rather than the other should be taken into account
    • irrespective of whether a rate-control or a rhythm-control strategy is adopted in patients with persistent AF, appropriate antithrombotic therapy should be used.
  3. In patients with permanent AF, who need treatment for rate control:
    • beta-blockers or rate-limiting calcium antagonists should be the preferred initial monotherapy in all patients
    • digoxin should only be considered as monotherapy in predominately sedentary patients.
  4. In patients with newly diagnosed AF for whom antithrombotic therapy is indicated (see section 11.6), such treatment should be initiated with minimal delay after the appropriate management of comorbidities.
  5. The stroke risk stratification algorithm (Figure 11.1) should be used in patients with AF to assess their risk of stroke and thromboembolism, and appropriate thromboprophylaxis given.

Each of these recommendations highlights areas of current clinical practice that the GDG believe would particularly benefit from guidance. Compliance with each of these key priority areas may be audited according to the corresponding audit criteria below.

Although items 4 and 5 may be audited using the same criteria, they address two different issues relating to antithrombotic therapy in AF. The first addresses the need for appropriate anti-thrombotic therapy in patients with AF upon initial diagnosis; the second addresses the need for a formal assessment of stroke risk and the administration of appropriate antithrombotic therapy based on that assessment.

3.2. AF care pathway

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Figure 3.1. AF care pathway (PDF, 57K)

3.3. Treatment strategy decision tree

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Figure 3.2. Treatment strategy decision tree (PDF, 57K)

3.4. Audit criteria

Table 3.1 lists the audit criteria identified to evaluate the impact of the implementation of the five key priority areas detailed above on clinical practice and health outcomes.

Table 3.1. Audit criteria for the key priorities for implementation.

Table 3.1

Audit criteria for the key priorities for implementation.

3.5. Areas for future research

The GDG has identified the following five questions as key areas for further research:


Although cardioversion is a core treatment for many patients with AF, there is little evidence that compares the different modes (electrical and pharmacological), particularly in terms of cost effectiveness. Further, the studies that have considered the efficacy of preloading with antiarrhythmic drugs prior to electrical cardioversion have not reported long-term efficacy in maintaining sinus rhythm, or the cost effectiveness of this strategy.


Echocardiography allows cardiac abnormalities such as left ventricular impairment to be diagnosed earlier than would be possible from signs and symptoms alone. However, no study has addressed the issue of whether performing routine echocardiography on all newly diagnosed AF patients would be more cost effective in diagnosing and treating heart disease earlier, than performing echocardiography only on those patients in whom there is a clinical suspicion of undiagnosed heart disease.

  • What is the cost effectiveness of performing a routine echocardiographic examination in all newly diagnosed AF patients, compared to only selective examination based on clinical criteria?

Anticoagulation with antiplatelet therapy

In the general AF population, the evidence suggests that combined therapeutic anticoagulation with antiplatelet therapy does not reduce the incidence of stroke or thromboembolism compared with therapeutic anticoagulation alone, and it may increase the incidence of bleeding. However, it is unclear whether there are certain subgroups of patients with AF for whom the therapeutic effects of combination therapy may be greater than either monotherapy. In particular, it is unclear whether combination therapy is justified in those AF patients who have stent implantation or a history of myocardial infarction (MI).

  • Is there any additional benefit, in terms of overall vascular events, from combined anticoagulation with antiplatelet therapy for any subgroups of patients with AF such as those with prior MI or stent implantation?

Pill-in-the-pocket treatment

Some patients with paroxysmal AF may have paroxysms infrequently. In these patients, the continuous use of antiarrhythmic drugs to suppress paroxysms may not be justified relative to their toxicity. No study has been undertaken in such patients in a UK population to determine whether a pill-in-the-pocket treatment strategy would be clinically or cost effective compared with either the emergency department administration of treatment or continuous antiarrhythmic drug therapy.

Anticoagulation in paroxysmal AF

The frequency of paroxysms in patients with paroxysmal AF varies widely between patients. It remains unclear, however, whether the risk of stroke or thromboembolism varies between those with only infrequent paroxysms and those with more frequent paroxysms. It is also unclear whether, if the risk of stroke or thromboembolism is reduced in those with infrequent paroxysms, the use of anticoagulation is justified in such a low-risk group.

  • What is the optimal anticoagulation strategy for those patients with paroxysmal AF who have infrequent paroxysms, and those who have more frequent paroxysms?
Copyright © 2006, Royal College of Physicians of London.

All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher.

Cover of Atrial Fibrillation
Atrial Fibrillation: National Clinical Guideline for Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 36.
National Collaborating Centre for Chronic Conditions (UK).

NICE (National Institute for Health and Care Excellence)

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