1. Why this matters for MRCGP

Atrial fibrillation (AF) is common, often asymptomatic, and may first appear as an irregular pulse, palpitations, breathlessness, dizziness, chest discomfort, stroke, or a wearable-device irregular pulse alert.

• AKT questions often test the next best step: confirm with a 12-lead electrocardiogram (ECG), decide admission versus primary-care management, assess stroke and bleeding risk, and avoid unsafe anticoagulant shortcuts.
• SCA stations test whether you can explain stroke prevention without frightening the patient, discuss bleeding risk realistically, and safety-net symptoms that change urgency.
• The big GP risk is treating unstable or very recent-onset AF as routine, or missing anticoagulation when it is indicated.

2. GP Bottom Line

• Do not diagnose AF from pulse alone: suspect it from an irregular pulse, symptoms, complication, risk factor, or device alert, then confirm with a 12-lead ECG.
• Urgency changes with stability and timing: new-onset AF within 48 hours, haemodynamic instability, severe symptoms, very fast or very slow ventricular rate, decompensated heart failure, stroke or transient ischaemic attack need admission or urgent specialist input.
• Stable primary-care AF is about stroke prevention and rate control: use CHA2DS2-VASc for stroke risk and ORBIT for bleeding risk. For non-valvular AF, offer a direct-acting oral anticoagulant (DOAC) if CHA2DS2-VASc is 2 or above, and consider a DOAC for a man with score 1, after bleeding-risk discussion.
• Do not apply CHA2DS2-VASc risk stratification in AF with severe mitral stenosis, mechanical valve prosthesis, known atrial thrombus or hypertrophic cardiomyopathy; these groups require anticoagulation and should follow specialist/local pathway advice.
• Exam trap: aspirin monotherapy is not for AF stroke prevention, and anticoagulation should not be withheld solely because of age or falls risk.

3. 60 Second Exam Snapshot

• AF is an irregular and often rapid ventricular rhythm caused by uncoordinated atrial electrical activation.
• Suspect AF with an irregular pulse, palpitations, breathlessness, chest pain, dizziness, syncope, fatigue, stroke or transient ischaemic attack, or self-initiated device notification.
• Confirm AF with 12-lead ECG. If paroxysmal AF is suspected but not captured, use ambulatory ECG monitoring according to symptom frequency.
• Emergency admission is needed for haemodynamic instability, severe symptoms, acute decompensated heart failure, serious complications, or serious underlying cause.
• For non-valvular AF, offer a DOAC for CHA2DS2-VASc score 2 or above; consider a DOAC for a man with score 1; do not anticoagulate under-65s with no risk factors other than sex.
• First-line rate control is a standard beta-blocker other than sotalol, or diltiazem or verapamil, unless rate control is not appropriate.
• Review rate-control treatment within 1 week of starting or dose titration; review controlled AF at least annually.

4. Recognition and Diagnosis

• AF may be symptomatic or incidental. Symptoms can include palpitations, breathlessness or reduced exercise tolerance, chest tightness or pain, dizziness, syncope, fatigue, tiredness, or sleep disturbance. It may also present as a complication, such as stroke or transient ischaemic attack.
• Terminology:
  • Paroxysmal AF: stops within 7 days, usually within 48 hours.
  • Persistent AF: lasts longer than 7 days.
  • Longstanding persistent AF: lasts at least 12 months.
  • Permanent AF: means no further attempts are planned to restore or maintain sinus rhythm.
• Risk factors and causes include hypertension, ischaemic heart disease, heart failure, valvular heart disease, structural heart disease, intercurrent illness such as pneumonia or pulmonary embolism, chronic kidney disease, COPD, electrolyte disturbance, thyrotoxicosis, diabetes, sleep apnoea, increasing age, obesity, smoking, alcohol excess, endurance sport, and medicines such as thyroxine, lithium or beta-2 agonist bronchodilators.
• Assessment should check onset, duration, frequency, severity, impact, triggers, comorbidities, family history, previous investigations or treatment, current medicines and lifestyle factors.
• Examination should include radial pulse, auscultation at the apex, manual blood pressure, heart sounds and murmurs, lungs, signs of heart failure, and haemodynamic instability.
• Treat as haemodynamic instability if there is pulse over 150 beats/minute, systolic blood pressure under 90 mmHg, severe dizziness, syncope or loss of consciousness, ischaemic chest pain, or acute pulmonary oedema.
• A 12-lead ECG confirms AF when the rhythm shows absence of distinct repeating P waves, irregular atrial activations, irregularly irregular R-R intervals when atrioventricular conduction is not impaired, and usually a narrow QRS complex.
• Important differentials for an irregular pulse include atrial flutter, atrial extrasystoles, ventricular ectopics, sinus tachycardia, supraventricular tachycardias, multifocal atrial tachycardia, and premature atrial or ventricular contractions.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

• Irregular pulse makes AF possible, but does not reliably diagnose AF.
• Absence of an irregular pulse makes AF unlikely.
• Confirm with 12-lead ECG.

Investigation / interpretation

• If paroxysmal AF is suspected but not detected on ECG, use 24-hour ambulatory ECG if asymptomatic episodes are suspected or symptomatic episodes are less than 24 hours apart.
• Use longer ambulatory ECG, event recorder or other ECG technology if symptomatic episodes are more than 24 hours apart.
• Transthoracic echocardiogram is particularly relevant if structural or functional heart disease is suspected, rhythm control with cardioversion is being considered, or baseline echo affects long-term management.

Management / next best step

• New-onset AF within 48 hours is not routine: stable patients still need admission or urgent specialist cardiology advice.
• Rate control is first-line in non-acute AF except with reversible cause, heart failure thought primarily caused by AF, new-onset AF, atrial flutter suitable for ablation, or where rhythm control is more suitable.

Stroke prevention

• Use CHA2DS2-VASc in symptomatic or asymptomatic paroxysmal, persistent or permanent AF, atrial flutter, and continuing risk after cardioversion or catheter ablation.
• CHA2DS2-VASc: heart failure/left ventricular dysfunction 1, hypertension 1, age 75 or over 2, diabetes 1, stroke/TIA 2, vascular disease 1, age 65–74 1, female sex 1.
• For non-valvular AF, offer a DOAC if CHA2DS2-VASc is 2 or above, and consider a DOAC for a man with score 1, after bleeding-risk discussion.
• Do not apply CHA2DS2-VASc risk stratification in AF with severe mitral stenosis, mechanical valve prosthesis, known atrial thrombus or hypertrophic cardiomyopathy.
• Do not offer anticoagulation to people under 65 with AF and no risk factors other than sex.
• If anticoagulation is contraindicated or not tolerated, consider cardiology referral for specialist risk-reduction options such as left atrial appendage occlusion.

Bleeding risk

• Use ORBIT when starting or reviewing anticoagulation.
• ORBIT: 2 points for low haemoglobin/haematocrit or previous bleeding; 1 point for age over 74, eGFR under 60 mL/min/1.73 m², or antiplatelet treatment. ORBIT 0–2 is low, 3 medium, 4–7 high bleeding risk.
• Manage modifiable bleeding risks such as uncontrolled hypertension, frailty and falls risk, reduced creatinine clearance, antiplatelets, SSRIs, NSAIDs, excessive alcohol, and reversible anaemia.

Medicines / safety

• DOAC options include apixaban, dabigatran, edoxaban and rivaroxaban.
• If a DOAC is contraindicated, not tolerated or unsuitable, offer a vitamin K antagonist such as warfarin.
• Do not use aspirin monotherapy solely for AF stroke prevention.
• Do not stop anticoagulation solely because AF is no longer detectable.

Follow-up / monitoring

• Review within 1 week after starting or titrating rate control.
• Review controlled AF at least annually, including symptoms, pulse, manual blood pressure, stroke risk, bleeding risk, medicines, adherence and adverse effects.
• Reassess very low risk patients when they reach 65 or develop new comorbidities.

6. SCA Consultation Essentials

• Gather the time of onset, especially whether symptoms began within 48 hours. Ask about chest pain, breathlessness, syncope, severe dizziness, stroke or TIA symptoms, and triggers.
• Explain the plan in two stages: first confirm the rhythm with ECG; then reduce risk by addressing stroke prevention, bleeding risk, symptoms and heart rate.
• When discussing anticoagulation, be explicit that the decision is a balance between stroke prevention and bleeding risk.
• Do not agree to aspirin as a safer substitute. Do not accept age or falls alone as the reason to avoid anticoagulation.
• Safety-net: fast or irregular heartbeat with chest pain, shortness of breath, fainting, severe dizziness/falls, or suspected stroke/TIA needs emergency assessment. Bleeding that is severe or head injury while anticoagulated needs urgent assessment.

7. Red Flags / Escalation / Referral

• Treat as haemodynamic instability if pulse >150, SBP <90, severe dizziness, syncope, ischaemic chest pain, or acute pulmonary oedema.
• Arrange emergency hospital admission if:
  • New-onset AF within 48 hours with haemodynamic instability.
  • Severe symptoms due to rapid ventricular rate (>150 bpm) or very slow ventricular rate (<40 bpm).
  • Acute decompensated heart failure.
  • Stroke or transient ischaemic attack.
  • Serious potentially reversible trigger (e.g., pneumonia or thyrotoxicosis).
• Arrange hospital admission or seek urgent specialist cardiology advice if:
  • New-onset AF within 48 hours and the person is haemodynamically stable.
  • Suspected or confirmed pre-excitation syndrome (e.g., Wolff-Parkinson-White).
• Arrange cardiology referral or seek specialist advice if:
  • AF of unknown duration or onset more than 48 hours ago with uncertainty.
  • Stable AF with heart failure thought to be primarily caused by AF.
  • Suspected paroxysmal AF with uncertainty.
  • AF with structural heart disease (e.g., valvular heart disease).
• Refer within 4 weeks if treatment fails to control symptoms.

8. What the GP Should Do Today

• Assess: onset, symptom burden, pulse, manual blood pressure, stability, heart murmur, lung signs, complications, comorbidities, medicines and lifestyle factors.
• Investigate: arrange 12-lead ECG. Consider bloods (FBC, TFTs, HbA1c, lipids, U&Es, LFTs, magnesium) and CXR if lung pathology is suspected.
• Triage: decide emergency admission, urgent cardiology advice, routine cardiology referral, or primary-care management.
• Treat / advise: assess CHA2DS2-VASc and ORBIT, discuss anticoagulation, manage modifiable bleeding risks, and consider a DOAC first-line for non-valvular AF.
• Review: rate-control treatment within 1 week after starting or titration. Annual review once stable.
• Safety-net: explain when to contact for uncontrolled symptoms and give anticoagulant bleeding advice.
• Advise about driving safety and insurer cover.

9. Practical Use in GP: How to Apply This Topic

Before prescribing or advising

• Confirm AF with ECG. Establish whether onset is within 48 hours.
• Calculate stroke and bleeding risk.
• For DOACs, renal dosing depends on creatinine clearance (CrCl), not eGFR.
• Check pregnancy and breastfeeding status: DOACs are avoided; warfarin should not be used in pregnancy unless exceptional specialist-led circumstances apply.

Starting / advising

• For non-valvular AF, a DOAC is first-line.
• If rate control is appropriate, first-line options are a standard beta-blocker (not sotalol), or diltiazem or verapamil.
• Patient instructions:
  • Carry an anticoagulant alert card (DOAC) or Yellow book (warfarin).Rivaroxaban 15 mg or 20 mg must be taken with food.
  • Dabigatran capsules should be swallowed whole and not opened.

Review / monitoring

• DOAC monitoring: Baseline clotting, FBC, renal and liver function. Review at 1 month, then at least annually.
• Warfarin: Requires INR monitoring and Time in Therapeutic Range (TTR) review.
• Rate-control review: Target rest heart rate below 110 bpm (lenient) or below 80 bpm (strict).

10. Medicines, Investigations and Intervention Safety

• Transthoracic echocardiogram is not routine solely for stroke risk if anticoagulation is already agreed.
• DOACs: Do not need routine INR monitoring. Not for use in antiphospholipid syndrome or prosthetic heart valves.
  • Dabigatran contraindicated if CrCl <30 mL/min. Others avoided/not recommended if CrCl <15 mL/min.
• Warfarin: Target INR is 2.5. Poor control = TTR <65%, two INRs >5, one >8, or two <1.5 in 6 months.
• Rate-control drugs:
  • Beta-blockers: Check for contraindications (e.g., asthma, bradycardia, AV block).
  • Diltiazem/Verapamil: Do not use in Heart Failure with reduced Ejection Fraction (HFrEF). Avoid verapamil with a beta-blocker.
  • Digoxin: Monotherapy for sedentary people; monitor for toxicity (confusion, nausea, colour vision disturbance).
  • Amiodarone: Specialist use for rhythm control; requires liver, thyroid, and lung monitoring.

11. How to Explain It to the Patient

• “Your pulse is irregular, but we need an ECG to confirm whether this is atrial fibrillation.”
• “The main reason we take this seriously is that it can increase the chance of a stroke.”
• “The bleeding score helps us reduce avoidable bleeding risks and monitor you safely.”
• “Aspirin on its own is not recommended for preventing stroke from atrial fibrillation.”
• “If you start an anticoagulant, carry your alert card and seek urgent advice for bleeding that does not stop or a head injury.”

12. When the Plan Changes

• AF started within 48 hours: Needs admission or urgent specialist advice.
• Haemodynamically unstable: Needs emergency hospital admission.
• Normal ECG but episodic AF suspected: Arrange ambulatory ECG monitoring.
• Non-valvular AF with CHA2DS2-VASc ≥2: Anticogulation is a key discussion.
• Anticoagulation contraindicated: Consider referral for left atrial appendage occlusion.
• Treatment fails or symptoms persist: Prompt cardiology referral (within 4 weeks).
• Warfarin control is poor: Reassess and consider switching to a DOAC.

13. Common AKT / SCA Traps

• Diagnosing AF without ECG confirmation.
• Treating stable new-onset AF (within 48 hours) as routine.
• Missing admission for ventricular rates >150 or <40 with severe symptoms.
• Using CHA2DS2-VASc for exception groups (e.g., mechanical valves).
• Withholding anticoagulation solely due to age or falls risk.
• Prescribing aspirin monotherapy for stroke prevention.
• Using sotalol for initial rate control.
• Combining verapamil with a beta-blocker.
• Dosing a DOAC without checking creatinine clearance.

14. Common Exam Angles

• Angle: Irregular pulse on BP check. Challenge: Arrange 12-lead ECG.
• Angle: Palpitations started this morning. Challenge: Onset within 48 hours; needs admission or urgent advice.
• Angle: Older patient with falls risk. Challenge: Assess risks; falls alone are not a reason to withhold treatment.
• Angle: Persistent symptoms despite rate control. Challenge: Refer within 4 weeks.

15. 90 Second Audio Summary Script

Atrial fibrillation is an irregular heart rhythm that may cause palpitations, breathlessness, chest discomfort, dizziness, syncope or fatigue, but it may also be found incidentally. The key first step is not to diagnose it from pulse alone. If the pulse is irregular, arrange a 12-lead ECG. If symptoms are episodic and the ECG misses it, use ambulatory ECG monitoring based on how often symptoms occur.

Urgency depends on stability, symptom severity and timing. New-onset AF within 48 hours needs admission or urgent cardiology advice even if stable. Emergency admission is needed for haemodynamic instability, severe symptoms with very fast or very slow ventricular rate, acute decompensated heart failure, stroke or transient ischaemic attack, or a serious underlying trigger.

For stable primary-care AF, think stroke prevention and rate control. Use CHA2DS2-VASc for stroke risk and ORBIT for bleeding risk. For non-valvular AF, offer a direct-acting oral anticoagulant when the score is 2 or above, and consider it for a man with score 1. Do not use CHA2DS2-VASc risk stratification in severe mitral stenosis, mechanical valve prosthesis, known atrial thrombus or hypertrophic cardiomyopathy. Do not use aspirin alone for AF stroke prevention, and do not withhold anticoagulation just because of age or falls risk.

Rate control is first-line in many non-acute cases, but not when AF is new-onset, has a reversible cause, or heart failure is thought mainly caused by AF. Options include a standard beta-blocker other than sotalol, or diltiazem or verapamil; avoid verapamil with a beta-blocker and seek specialist advice before diltiazem with a beta-blocker.

Review rate-control treatment within a week, aiming for symptom control and an appropriate ventricular rate target. Review controlled AF at least annually. Refer within 4 weeks if symptoms remain uncontrolled or recur after cardioversion. Always give practical anticoagulant advice: carry the alert card or Yellow book, report significant bleeding or head injury, avoid missed or extra doses, take rivaroxaban 15 or 20 mg with food, and Dabigatran capsules should be swallowed whole and not opened.

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Important Disclaimer

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