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Practice Guidelines

Atrial fibrillation: diagnosis and management—summary of NICE guidance

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1150 (Published 21 May 2021) Cite this as: BMJ 2021;373:n1150
  1. Mark Perry, senior research fellow1,
  2. Sophia Kemmis Betty, health economics lead1,
  3. Nicole Downes, research fellow1,
  4. Neil Andrews, topic expert, consultant cardiologist2,
  5. Simon Mackenzie, guideline chair, medical director of System Improvement and Professional Standards South East Region3
  6. on behalf of the Guideline Committee
    1. 1National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
    2. 2Portsmouth Hospitals University NHS Trust, Portsmouth, UK
    3. 3NHS England and NHS Improvement, UK
    1. Correspondence to: M Perry mark.perry{at}rcp.ac.uk

    What you need to know

    • Bleeding risk assessment should be used to derive accurate absolute risk scores that can support discussion between clinician and patient about risk modification and appropriate vigilance during anticoagulation. It should not be used to set a threshold for who should be offered anticoagulation

    • The ORBIT bleeding prediction tool currently provides the most accurate level of absolute bleeding risk

    • Direct-acting oral anticoagulants (DOACs) should be used in preference to warfarin for most patients; the choice of DOAC depends on patient choice and clinical indication

    • Radiofrequency point-by-point ablation is the most cost effective treatment for people who have not responded to antiarrhythmic drugs, although laser and cryoballoon ablation may be appropriate in some patients

    • Continue anticoagulation after ablation according to risk tools

    This article summarises the updated National Institute for Health and Care Excellence (NICE) guideline, Atrial fibrillation: diagnosis and management,1 focusing on three areas where new evidence has led to a change in recommendations: bleeding risk prediction, anticoagulation, and ablation. We explain the Guideline Committee’s rationale for these recommendations and highlight challenges to implementation.

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee's experience and opinion of what constitutes good practice. Evidence levels for the recommendations reproduced here are given in italics in square brackets.

    Assessment of bleeding risks

    For predicting the need for anticoagulation in people diagnosed with atrial fibrillation, the CHA2DS2-VASc score was retained as the recommended stroke risk tool (fig 1) because it was the most accurate tool for discriminating between those at risk of stroke and those not at risk. In contrast, the choice of tool to assess bleeding risk was less based on discrimination ability and more on the ability to provide an accurate …

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