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Practice Guidelines

The management of atrial fibrillation: summary of updated NICE guidance

BMJ 2014; 348 doi: (Published 19 June 2014) Cite this as: BMJ 2014;348:g3655

This article has a correction. Please see:

  1. Clare Jones, senior research fellow/project manager1,
  2. Vicki Pollit, senior health economist1,
  3. David Fitzmaurice, professor of primary care2,
  4. Campbell Cowan, emeritus consultant cardiologist and guideline chair3
  5. On behalf of the Guideline Development Group
  1. 1Royal College of Physicians, National Clinical Guideline Centre, London NW1 4LE, UK
  2. 2Primary Care Clinical Sciences, University of Birmingham, UK
  3. 3Department of Cardiology, Leeds General Infirmary, Leeds, UK
  1. Correspondence to: C Jones clare.jones{at}

Atrial fibrillation is increasingly common,1 with more than 800 000 people being affected in England.2 Many people are managed in primary care without hospital involvement. The condition is a major cause of morbidity, particularly stroke, and it reduces life expectancy. Strokes caused by atrial fibrillation are largely avoidable—most can be prevented by anticoagulation. Yet uptake of anticoagulation by people with known atrial fibrillation who are at increased risk of stroke is suboptimal.3 4 5

Since the publication of the 2006 guidance, several developments relating to risk stratification, stroke prevention, and rhythm management have led to a partial update on the 2006 guidance. This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE).6


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 Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. All recommendations below should be in accordance with the NICE patient experience guideline,7 and the benefits and risks of treatment should be discussed with the patient.

Diagnosis and assessment

  • Perform manual pulse palpation to assess for the presence of an irregular pulse, which might be indicative of underlying atrial fibrillation in people presenting with any of the following: breathlessness or dyspnoea, palpitations, syncope or dizziness, chest discomfort, stroke or transient ischaemic attack. (Recommendation from 2006 guideline.)

  • Perform electrocardiography (ECG) in all people, whether symptomatic or not, in whom atrial fibrillation is suspected because an irregular pulse has been detected. (Recommendation from 2006 guideline.)

  • In people with suspected paroxysmal atrial fibrillation undetected by standard ECG:

    • -Use 24 hour ambulatory ECG in those with suspected asymptomatic episodes or symptomatic episodes less than …

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