Atrial Fibrillation Diagnosis

and Related Stroke Risk Assessment (in the absence of mitral stenosis and/or mechanical heart valves) and Management

A Step By Step Guide


  1. Offer a DOAC (apixaban, dabigatran, edoxaban, rivaroxaban) in preference to warfarin, unless contra-indicated, not tolerated, or unsuitable.
  2. If already treated with warfarin and stable, discuss switching to a DOAC at next routine appointment, unless DOAC contra-indicated, not tolerated, or unsuitable. In patients treated with warfarin, ensure good INR control (review TTR (time in therapeutic range)). Poor control and an indication to reassess anticoagulation is defined by NICE NG196 as 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months, 2 INR values less than 1.5 within the past 6 months, and/or TTR less than 65%.
  3. Do not offer anticoagulation for stroke prevention if very low risk of stroke i.e. CHA2DS2-VASc score of 0 in men, CHA2DS2 -VASc score 1 in women).
  4. Review concordance including quality of anticoagulation and monitoring of renal function (use Cockcroft-Gault equation) MHRA advice on DOACs
  5. Review patients at least annually or earlier if stroke and/ or bleeding risk changes.
  6. Review patients who have not been anticoagulated because of a high bleeding risk; this should be reviewed regularly and the decision reconsidered.
  7. In patients with a diagnosis of AF, anticoagulation should not be routinely stopped if AF is no longer detected, and any decision about anticoagulation should be based on an up to date assessment of stroke (CHA2DS2-VASc) and bleeding (ORBIT) risks, and individual patient preference.
  8. For guidance about referral for specialized management, see NICE NG196.