Atrial Fibrillation in General Practice: Detection, Anticoagulation & Rate Control
Practical AF management from opportunistic detection to stroke prevention
Atrial fibrillation is the most common sustained cardiac arrhythmia, affecting 2–4% of the general population and rising sharply with age. This guide covers opportunistic detection, CHA₂DS₂-VASc scoring, DOAC selection, rate vs rhythm control, and when to refer.
Clinical Decision Support: This article is for educational purposes and supports — not replaces — clinical judgment. Always verify with current national guidelines, BNF, and specialist consultation when needed.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in primary care, affecting approximately 2–4% of the general population and rising to over 10% in those aged 80 and above. It is responsible for approximately 20–30% of all ischaemic strokes, many of which are preventable with appropriate anticoagulation. The GP's role in AF management spans opportunistic detection, risk stratification, anticoagulation initiation, and long-term monitoring.
Detection: Opportunistic Pulse Palpation
NICE recommends opportunistic pulse palpation in all patients aged ≥65 years at every clinical encounter. An irregular pulse should prompt a 12-lead ECG. AF is diagnosed on ECG by the absence of distinct P waves and an irregularly irregular ventricular response. Single-lead ECG devices (e.g., AliveCor KardiaMobile) are validated for AF detection and can be used in primary care.
Stroke Risk Assessment: CHA₂DS₂-VASc Score
| Risk Factor | Points |
|---|---|
| Congestive heart failure | 1 |
| Hypertension | 1 |
| Age ≥75 years | 2 |
| Diabetes mellitus | 1 |
| Stroke/TIA/thromboembolism (prior) | 2 |
| Vascular disease (MI, PAD, aortic plaque) | 1 |
| Age 65–74 years | 1 |
| Sex category (female) | 1 |
Anticoagulate if CHA₂DS₂-VASc ≥2 in men or ≥3 in women. Consider anticoagulation if score is 1 in men or 2 in women. Do not anticoagulate for score 0 in men or 1 in women (female sex alone). Always assess bleeding risk (HAS-BLED) before prescribing.
DOAC Selection: Practical Guide
| DOAC | Dose | Renal Adjustment | Key Consideration |
|---|---|---|---|
| Apixaban (Eliquis) | 5 mg BD (2.5 mg BD if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥133) | Avoid if eGFR <15 | Preferred in renal impairment; twice daily |
| Rivaroxaban (Xarelto) | 20 mg OD with evening meal (15 mg OD if eGFR 15–49) | Avoid if eGFR <15 | Once daily — better adherence; take with food |
| Edoxaban (Lixiana) | 60 mg OD (30 mg OD if eGFR 15–50, weight ≤60 kg, or P-gp inhibitor) | Avoid if eGFR <15 | Requires parenteral anticoagulation bridge for first 5–10 days |
| Dabigatran (Pradaxa) | 150 mg BD (110 mg BD if age ≥80 or high bleed risk) | Avoid if eGFR <30 | Only DOAC with reversal agent (idarucizumab); dyspepsia common |
Rate Control vs Rhythm Control
For most patients with AF, rate control is the initial management strategy. The AFFIRM and RACE trials demonstrated that rate control is non-inferior to rhythm control for mortality and cardiovascular outcomes in most patients. However, rhythm control is preferred in younger patients, those with AF-related symptoms, or those with heart failure with reduced ejection fraction (HFrEF).
Rate Control Targets and Drugs
- Target resting heart rate: <110 bpm (lenient) or <80 bpm (strict — for symptomatic patients)
- First-line: Beta-blocker (bisoprolol 2.5–10 mg OD) or rate-limiting CCB (diltiazem or verapamil — avoid in HFrEF)
- Second-line: Add digoxin (particularly in sedentary patients or HFrEF)
- Avoid rate-limiting CCBs in HFrEF — use beta-blocker + digoxin combination instead
When to Refer
- New AF with haemodynamic instability — emergency admission
- Symptomatic AF despite rate control — consider rhythm control/cardioversion
- AF with pre-excitation (WPW) — urgent cardiology referral
- Consideration for catheter ablation (paroxysmal AF, younger patients, failed antiarrhythmics)
- AF with heart failure — joint cardiology/heart failure team management
- Uncertainty about anticoagulation (e.g., high bleeding risk, renal impairment)
Key Clinical Takeaways
- Opportunistic pulse palpation in all patients ≥65 years; confirm AF with 12-lead ECG
- Calculate CHA₂DS₂-VASc: anticoagulate if ≥2 (men) or ≥3 (women)
- DOACs are preferred over warfarin for non-valvular AF
- Rate control target: <110 bpm resting; use beta-blocker or rate-limiting CCB
- Rhythm control preferred in younger, symptomatic patients or HFrEF
- Never stop anticoagulation after cardioversion — AF recurrence risk is high