Atrial Fibrillation (AF) – Persistent (>7 days)

Objectives

Therapeutic:

  1. Relieve symptoms – often only rate control required; diuretic may also be needed (often only on temporary basis).
  2. Target ventricular (apex or ECG) rate <110bpm. If still symptomatic, aim for lower rate, <80bpm.
  3. Assess thromboembolic risk and anticoagulate as appropriate.
  4. In some cases, consider restoration of sinus rhythm by electrical or pharmacological cardioversion (only attempt chemical or electrical cardioversion after adequate anticoagulation; risk of thromboembolism if not anticoagulated; limited long-term success).
  5. Optimal management of concomitant cardiovascular disease.

Diagnostic:

  1. Exclude thyrotoxicosis.
  2. Exclude acute (binge) or chronic alcohol consumption.
  3. Exclude mitral stenosis and other valve problems, see below.
  4. Determine if there are echocardiographic risk factors for stroke or thromboembolism.
  5. Identify concomitant left ventricular (LV) systolic dysfunction and heart failure.

Essential investigations

  1. A resting 12-lead ECG – confirms diagnosis, shows the ventricular rate, may indicate presence of structural heart disease.
  2. U&Es, LFTs, FBCs and thyroid function tests.
  3. A transthoracic echocardiogram – excludes mitral stenosis, gives structural and functional assessment of heart (e.g. whether LV systolic dysfunction / hypertrophy) and therefore helps identify need for anticoagulation.

N.B. Investigation should not delay treatment to slow the ventricular rate and reduce the risk of thromboembolism.

Ventricular rate control

    1. Target ventricular (apex or ECG) rate <110bpm. If still symptomatic then aim for lower rate, <80bpm.
    2. Patients without heart failure should be started on either a beta-blocker or rate-limiting calcium-channel blocker (CCB):
        • Beta-blocker – choice includes:
          • Bisoprolol oral 2.5mg daily (consider 1.25mg in frail, elderly patients) and up-titrate to 5mg once daily if ventricular rate is still >110bpm, or
          • Atenolol oral 25mg twice daily and up-titrate to 50mg twice daily if ventricular rate is still >110bpm. In frail or elderly patients consider starting dose of atenolol oral 25mg once daily.
      • Rate-limiting CCB i.e. verapamil - start with verapamil (slow release) oral 120mg once daily and titrate up to 240mg once daily if ventricular rate still >110bpm.

N.B. Beta-blockers and rate-limiting CCBs (e.g. verapamil or diltiazem) must not be combined, unless on the specific advice of a cardiologist (and even then generally only when the patient already has a transvenous pacemaker or ICD).

Digoxin has a limited role as first-line treatment for ventricular rate control. It can be used in combination with a beta-blocker or rate-limiting CCB when control of the ventricular rate is difficult.

  1. Patients with heart failure should be started on digoxin or beta-blocker as appropriate and follow the heart failure guideline.

Heart failure / LV Systolic Dysfunction

See heart failure guideline. ACE inhibitors and beta-blockers are strongly recommended. Beta-blockers must be initiated under direction of a hospital physician. Rate-limiting CCBs should be avoided.

Patients to refer for specialist assessment / consideration of cardioversion or ablation

  • Young age (<65 years)
  • Reversible precipitating cause of AF (e.g. alcohol binge, thyrotoxicosis, pneumonia, recent surgery) and no major structural or functional heart disease.
  • Difficulty with ventricular rate control
  • Valve disease
  • LV systolic dysfunction / heart failure
  • AF causing symptomatic limitation despite rate-limiting treatment e.g. heart failure, excessive exertional breathlessness, undue fatigue.
  • Patients with typical atrial flutter (are generally more amenable to ablation with around a 90% procedural success rate)

Prevention of stroke / thromboembolism

  • Patients with both recurrent paroxysmal AF and sustained AF have a high risk of thromboembolism, particularly stroke. Compared to subjects without AF the absolute risk of stroke is, on average, increased by about 4-fold and the risk of stroke is about 4% per annum.
  • This risk is greatest in patients with certain risk factors (for further information, see ADTC290  - link only active via NHS network).
  • For primary prevention, anticoagulants can substantially reduce risk of thromboembolism.
  • Patients with AF and a previous stroke or transient ischaemic attack (TIA) have an absolute risk of a further stroke of the order of 10–12% per annum and an absolute benefit of approximately 80 fewer strokes per 1000 patient years of treatment.

    N.B. Patient with a suspected stroke or TIA should first be referred for rapid specialist assessment – see Management of Stroke guideline.

  • Advanced age is not a contraindication to anticoagulation.
  • In patients with 'lone' AF, i.e. AF in a structurally normal heart and no other risk factors for thromboembolic disease, no anti-thrombotic or anticoagulant therapy is recommended.

Who should receive anticoagulant therapy

  • Patients with clinical risk factors or echocardiographic risk factors.
  • Patients without contraindications to anticoagulant therapy.

Cautions / contraindications to anticoagulant therapy

  • Absolute contraindications include: active bleeding, pregnancy (seek obstetrician advice).
  • Relative contraindications include: significant bleeding risk e.g. active peptic ulcer or recent head injury; hepatic disease associated with coagulopathy; recent major bleed (within 6 months); previous cerebral haemorrhage, stroke within 14 days.
  • Cautions include: severe frailty, alcohol abuse.

Choice of agent: direct oral anticoagulant agents (DOACs) vs warfarin

For advice on choice of anticoagulant and prescribing considerations, refer to ADTC290 (link only active via NHS network).

Remember: DOACS are indicated only in those patients who have non-valvular AF; not those with moderate-severe mitral stenosis or a mechanical valve. Patients with tissue valve or mitral valve repair can still be considered for DOAC. 

Combined anticoagulant and antiplatelet therapy

Continued antiplatelet therapy is not indicated in patients with stable coronary artery disease (>1 year after acute coronary syndrome or coronary intervention) who also have AF and are on an anticoagulant. After percutaneous coronary intervention, short-term combined therapy is used according to cardiologist advice.

Initiation and monitoring of warfarin therapy

Use the Age-adjusted warfarin induction regimen (see warfarin prescription chart). There is no need to bridge warfarin with another anticoagulant for patients who are not on any prior anti-coagulation and are being newly initiated on warfarin.  Warfarin can be loaded either as an inpatient or urgently as an outpatient – liaise with warfarin clinic for advice as to when this would be possible.  In all cases, follow up with the warfarin clinic needs to be arranged prior to discharge from hospital and this should be communicated to the patient.

If the patient is already on an anticoagulant for another indication (e.g. deep-vein thrombus) this can be continued as the warfarin is initiated to bridge until the INR is therapeutic, after which it should be discontinued. 

Contact anticoagulation pharmacist for further information.

Drugs for atrial fibrillation

Long-term Anticoagulation

For choice, see ADTC290 (link only active via NHS network). 

Chemical cardioversion

Amiodarone

For chemical cardioversion (see IV or oral dosing guidance in Recent onset AF and flutter guideline).

Check baseline CXR, LFTs, U&Es and thyroid function tests (ideally before starting or if not then as soon as possible). Note common interactions including antifungals, digoxin, macrolide antibiotics, simvastatin, warfarin (list not exhaustive; see BNF for a full list of drugs and more details).

Rate control

Beta-blockers

See above for dosing guidance.

Digoxin

In frail elderly patients or patients with very low body weight, lower loading and maintenance doses than those advised below may be required. If further advice is required then contact your clinical pharmacist, or Medicines Information (see Appendix 6 for contact details) or out-of-hours the on-call pharmacist.

Loading dose – normal renal function:

  • Digoxin oral (preferred route) 500micrograms followed 6 hours later by one or two further doses of 500micrograms each at least 6 hours apart or
  • Digoxin IV 500micrograms followed 6 hours later by one or two further doses of 250micrograms each at least 4–6 hours apart.

Loading dose – renal impairment (creatinine clearance <30ml/minute):

  • Digoxin oral (preferred route) 500micrograms followed 6 hours later by either 250micrograms as a single dose or 375micrograms in divided doses >6 hours apart or
  • Digoxin IV 250–500micrograms

N.B. Digoxin injection: 25micrograms = 0.1ml. Additional loading doses may be required; give according to ventricular (heart rate) response.

Maintenance daily dose: The tables below outline digoxin daily maintenance dosing for patients <60kg (see table 2) and ≥60kg (see table 3).

Table 2 – Digoxin daily maintenance dose if <60kg

CrCl* Oral IV
>50ml/min 250–312.5micrograms 175–200micrograms
20–50ml/min 125–187.5micrograms 100micrograms
<20ml/min 62.5–125micrograms 50–75micrograms
*Creatinine clearance - Use MD+CALC for Cockcroft-Gault equation

Table 3 – Digoxin daily maintenance dose if ≥60kg

CrCl* Oral IV
>50ml/min 250–375micrograms 175–250micrograms
20–50ml/min 187.5micrograms 125micrograms
<20ml/min 62.5–125micrograms 50–75micrograms
*Creatinine clearance - Use MD+CALC for Cockcroft-Gault equation

Target concentration range: 0.5–2micrograms/L (6–24 hours after the dose)

Time to steady state: 5–10 days

Concentration increased by amiodarone, diltiazem, quinine, verapamil (list not exhaustive; see BNF for a full list of drugs and more details).

Atrial Fibrillation and Lifestyle

Patients with atrial fibrillation who are significantly overweight (BMI > 27kg/m2) should be encouraged to try to lose weight. Studies have shown that overweight and obese patients who manage to lose at least 10% of their body weight are more likely to have successful outcomes from treatment for atrial fibrillation compared to those who fail to lose weight (or who gain weight). Patients can be offered referral to local services (e.g. Ayrshire Weigh to Go) to help with this. 

Physical activity is encouraged. Patients should be encouraged to undertake moderate (or even high intensity) exercise, and many patients will find that their exercise capacity improves and their symptom burden reduces with activity.

Moderate caffeine intake is not a risk factor for AF, and it is safe for patients with AF to take caffeinated drinks.

Alcohol, even in small amounts, might be a trigger for AF in some patients, and moderation or even abstinence should be discussed with the patient.

 

Guideline reviewed April 2025
Page updated August 2025



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