Haemodynamically unstable AF (shock, ischaemia, syncope, heart failure) needs emergency synchronised DC cardioversion. Anticoagulate before cardioversion unless AF is clearly under 48 h.
Stroke prevention
- CHA2DS2-VASc: offer anticoagulation at score 2 or more; consider it for men scoring 1
- DOAC first-line if eligible (check renal function, weight, interactions)
- Assess bleeding risk with ORBIT (NICE preference) and treat modifiable factors
- Do not use aspirin for stroke prevention; do not withhold on bleeding risk alone
Rate control (first-line for most)
- Beta-blocker (not sotalol) or rate-limiting CCB (diltiazem or verapamil)
- Do not use a rate-limiting CCB in heart failure with reduced EF
- Digoxin only if sedentary or non-paroxysmal, or add-on
- Target resting rate under 110 bpm initially, then symptom-guided
Stable, rate-controlled
- Rate control first line
- Assess CHA2DS2-VASc and ORBIT
- Anticoagulate by score
Symptomatic / fast
- Rate control, treat the trigger
- Consider rhythm control if under 48 h
- Seek cause: sepsis, PE, thyroid
Haemodynamically unstable
- Shock, ischaemia, syncope, heart failure
- Emergency synchronised DC cardioversion
- Senior help now
New or fast AF
1
1. Assess
ECG confirms AF. Look for a trigger: sepsis, PE, ischaemia, thyroid, alcohol, electrolytes. Bloods including TFT and U&E.
ECG confirms AF. Look for a trigger: sepsis, PE, ischaemia, thyroid, alcohol, electrolytes. Bloods including TFT and U&E.
↓
2
2. Stabilise
Unstable: emergency synchronised DC cardioversion. Stable: rate control and treat the precipitant.
Unstable: emergency synchronised DC cardioversion. Stable: rate control and treat the precipitant.
↓
3
3. Rate vs rhythm
Rate control first-line for most. Consider rhythm control if onset under 48 h, a reversible cause, heart failure, or symptoms persist despite rate control.
Rate control first-line for most. Consider rhythm control if onset under 48 h, a reversible cause, heart failure, or symptoms persist despite rate control.
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4
4. Anticoagulate
DOAC first-line unless active major bleed. Warfarin if a mechanical valve or moderate-to-severe mitral stenosis, or if a DOAC is unsuitable.
DOAC first-line unless active major bleed. Warfarin if a mechanical valve or moderate-to-severe mitral stenosis, or if a DOAC is unsuitable.
| Factor | Points |
|---|---|
| Congestive heart failure | 1 |
| Hypertension | 1 |
| Age 75 or older | 2 |
| Diabetes | 1 |
| Prior stroke, TIA or thromboembolism | 2 |
| Vascular disease | 1 |
| Age 65 to 74 | 1 |
| Sex category (female) | 1 |
DOAC checks
- Creatinine clearance and weight extremes
- Interactions (azole antifungals, some HIV and epilepsy drugs)
- Peri-procedure interruption per local guidance
Pitfalls
- Treating AF without seeking a trigger (PE, sepsis)
- Under-anticoagulating a high CHA2DS2-VASc
- Rate-limiting CCB with reduced LV function
- Using aspirin for stroke prevention
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026