The National Institute for Health and Care Excellence (NICE) has published an updated guideline on the diagnosis and management of atrial fibrillation (AF).
The new guidance addresses several areas where new evidence has become available since the publication of previous guideline in 2014. These include bleeding risk calculation, the role of newer anticoagulants and ablation.
Evidence shows that ORBIT is the most accurate tool for predicting absolute bleeding risk in people with AF. However, the guideline acknowledges that other bleeding risk tools, including HAS-BLED which NICE previously recommended, may need to be used until ORBIT is embedded in clinical pathways and electronic systems.
The guideline recommends anticoagulation with a direct-acting oral anticoagulant for people with AF and a high risk of stroke (CHA2DS2-VASc score ≥2), taking into account the risk of bleeding. For men with a moderate risk of stroke (CHA2DS2-VASc score 1), 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 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 AF, the updated guideline says radiofrequency point-by-point ablation should be considered or if this is not suitable, either cryoballoon ablation or laser balloon ablation.
The updated guideline is available here.
