New updated NICE guidance on atrial fibrillation

NICE has published updated guidance on the diagnosis and management of atrial fibrillation (AF) including use of tools to calculate the risk of bleeding, the role of newer anti-clotting drugs and treatments for abnormal sources of electrical impulses in the heart.

New recommendations for diagnosis of AF include performing a 12-lead electrocardiogram (ECG) if an irregular pulse is detected in people with suspected AF with or without symptoms.

In people with suspected paroxysmal atrial fibrillation undetected by 12-lead ECG recording, use an ambulatory ECG monitor, event recorder or other ECG technology is recommended for a period appropriate to detect AF if symptomatic episodes are more than 24 hours apart.

The guidance also recommends a new tool called ORBIT to predict the risk of bleeding in people with AF, but acknowledges that other bleeding risk tools, including HAS-BLED, may need to be used until ORBIT is embedded in clinical pathways and electronic systems used by clinicians.

Treatment of atrial fibrillation recommendations

NICE recommends that anticoagulation with drugs called direct-acting oral anticoagulants should be offered to people with AF who have a high risk of stroke, taking into account the risk of bleeding. For men with a moderate risk of stroke, the guideline recommends that anticoagulation with a direct-acting oral anticoagulant should be considered.

Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance.

A vitamin K antagonist (for example warfarin) is recommended as an alternative if direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable.

When drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic intermittent or persistent AFAF the updated guideline says radiofrequency point-by-point ablation should be considered or, if this isn’t suitable, either cryoballoon ablation or laser balloon ablation can be considered.

Diagnosis with a 12-lead electrocardiogram

The updated guidance was welcomed by the AF Association, but the charity said it was disappointed that the guideline requires a 12-lead electrocardiogram (ECG) to diagnose AF rather than a manual pulse rhythm check and use of modern mobile ECG technology, which has previously been approved by NICE.

It said that this could lead to a delay in diagnosis and, importantly, delay a person with AF receiving vital anticoagulation therapy to protect against AF-related stroke. This is because not all GP clinics have access to a 12-lead ECG.

Mrs Trudie Lobban MBE, Founder and CEO of AF Association, says: “We are glad that, in its new guideline, NICE acknowledges the importance of involving the person with AF in the decision-making process. As we advocate in our AF White Paper, people with AF must be empowered to take charge of their condition and be encouraged to use ‘self-care’ to improve their quality of life.

“However, we are worried by NICE’s recommendation that a 12-lead ECG must be used to diagnose AF as we believe that this may delay diagnosis and, potentially, may mean that a person with AF experiences a devastating AF-related stroke before they can receive the appropriate anticoagulation therapy.”