The principal pharmacological intervention in AF is anticoagulation, except in the minority of people where benefits of anticoagulant therapy does not outweigh the bleeding risk.19

NICE recommends risk assessment using the CHA2DS2€‘VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category).

Those with a higher stroke risk - a CHA2DS2€‘VASc score of 2 or more - can be offered a direct-acting anticoagulant such as apixaban, dabigatran, edoxaban or rivaroxaban. A score of 1 in men may also indicate direct anticoagulant use.

Anticoagulant therapy should not be offered to people under the age of 65 with a low stroke risk (equating to a CHA2DS2€‘VASc score of 0 for men or 1 for women).

If a direct-acting anticoagulant is contraindicated or unsuitable, then warfarin or another vitamin-K antagonist can be offered. NICE says not to offer aspirin monotherapy solely for stroke prevention to people with AF. Heparin may be suitable (temporarily) for people with new€‘onset atrial fibrillation who are receiving no, or subtherapeutic, anticoagulation therapy. 

NICE is now encouraging doctors to consider switching AF patients who have been stable on warfarin or other vitamin K antagonist to direct anticoagulants, taking into account their time in therapeutic range. This should be assessed from INR testing over 6 months as well as the person’s circumstances and adherence.

Non-drug approaches include a procedure called percutaneous occlusion of the left atrial appendage (or LAAO) to close off a small pouch in the left atrium where 90 per cent of blood clots occur due to AF.19,20