The updated guideline addresses several areas where new evidence
has become available since publication of the previous guideline in
2014. These include the use of tools to calculate the risk of
bleeding when considering the use of anti-clotting drugs
(anticoagulants), the role of newer anti-clotting drugs, and the
use of treatments that aim to destroy or isolate the abnormal
sources of electrical impulses in the heart that may be driving AF
(ablation).
Accurate knowledge of bleeding risk supports shared decision
making and has practical benefits (for example, increasing a
person’s confidence and willingness to have anti-clotting
treatment when risk is low and prompting a discussion of how to
reduce the risk of bleeding when risk is high). Evidence shows
that a tool called ORBIT is the most accurate one for predicting
the risk of bleeding in people with AF. However, the guideline
acknowledges that other bleeding risk tools, including HAS-BLED
which NICE’s previous guideline recommended, may need to be used
until ORBIT is embedded in clinical pathways and electronic
systems used by clinicians.
The guideline recommends that anticoagulation with drugs called
direct-acting oral anticoagulants should be offered to people
with atrial fibrillation 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 atrial
fibrillation the updated guideline says radiofrequency
point-by-point ablation (which uses heat energy to precisely
disable heart tissue that causes irregular heartbeats) should be
considered or, if this isn’t suitable, either cryoballoon
ablation (a type of ablation which uses freezing energy rather
than heat) or laser balloon ablation (which uses catheters inside
the heart to ablate tissue using a laser guided by a camera) can
be considered.
Atrial fibrillation is the most common heart rhythm disorder
(affecting approximately 2% of the adult population), and
estimates suggest its prevalence is increasing. Atrial
fibrillation causes palpitations and breathlessness in many
people but it may be silent and undetected. If left untreated it
is a significant risk factor for stroke and other morbidities: it
is estimated that it is responsible for approximately 20% of all
strokes and is associated with increased mortality. Men are more
commonly affected than women and the prevalence increases with
age and in underlying heart disease, diabetes, obesity and
hypertension.
The aim of treatment is to prevent complications, particularly
stroke, and alleviate symptoms.
