Does the patient need anticoagulation?

The need for anticoagulation should be considered in patients with any history of AF, not just if they are in AF currently, i.e. the following groups should be assessed:

• symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
• atrial flutter
• a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm or catheter ablation

See:

AF - Risk calculation

If treatment is indicated, which anticoagulant?

For many years warfarin was the anticoagulant of choice in atrial fibrillation. This changed following the development of

direct oral anticoagulants (DOACs)

. These have the advantage of not requiring regular blood tests to check the INR and now recommended as the first-line anticoagulant for patients with AF. If a patient was previously started on warfarin, NICE recommend discussing switching to a DOAC during a routine follow-up appointment.

The following DOACs are recommended by NICE for reducing stroke risk in AF:

• apixaban
• dabigatran
• edoxaban
• rivaroxaban

Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated.

Aspirin is not recommended for reducing stroke risk in patients with AF.