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. Confirm AF with a good quality 12 lead ECG. If not detected and paroxysmal AF is suspected, use ambulatory monitoring (24 hour ambulatory ECG monitor if episodes occur < 24 hourly, or ambulatory monitoring event recorder or other appropriate technology (including AliveCor) for longer periods if occurring less frequently). Check bloods; FBC, U&Es, LFT, TFT, coagulation screen and HbA1c.
  2. If unstable or breathless on mild exertion and/or at rest, consider emergency admission.
  3. Use CHA2DS2-VASc stroke risk score to assess stroke risk.
  4. Consider indications for an echocardiogram (baseline echo is important for long term management, assessing any risk of structural heart disease, considering rhythm control management, refinement of thromboembolic risk) (see NICE NG196, section 1.3).
  5. Ensure appropriate rate control and/or rhythm control management plans are in place (see NICE NG196 for more guidance).
  6. Remember the natural history of AF may be modifiable. Check for the presence of potentially modifiable risk factors, not an exhaustive list but for example hypertension, elevated weight/BMI, hyperthyroidism, alcohol consumption, obstructive sleep apnoea.
  7. Mitral stenosis is associated with a high stroke risk in AF.
  8. Estimate bleeding risk using ORBIT bleeding risk score.
  9. Monitor and modify risk factors for bleeding (including uncontrolled hypertension, poor INR control on warfarin, concurrent medication including antiplatelets, SSRIs, NSAIDs, harmful alcohol consumption, reversible causes of anaemia). Age and risk of falls alone are not a reason to withhold anticoagulation.
  10. Offer anticoagulation if CHA2DS2-VASc score 2 or above and consider in men with CHA2DS2-VASc score of 1, taking into account the ORBIT bleeding risk score (the currently used HAS-BLED score may continue to be used until clinicians are familiar with the ORBIT bleeding risk score and it has been incorporated into primary care IT systems).