Atrial fibrillation in an adult
AF on a 12-lead ECG, or 30 s or more on a single-lead ECG. ESC 2024 AF-CARE approach.
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Atrial Fibrillation Management (ESC 2024 AF-CARE)
Atrial Fibrillation Management (ESC 2024 AF-CARE): Atrial fibrillation in an adult → Pregnancy or child: get specialist advice → Haemodynamically unstab...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Warning Pregnancy or child: get specialist advice
This pathway is for non-pregnant adults.
- Pregnancy: urgent cardiology and obstetric advice; drug choices differ
- Pregnancy with instability or pre-excited AF: immediate DC cardioversion
- Child: paediatric cardiology advice
03Decision Haemodynamically unstable due to AF?
Shock, hypotension, acute ischaemia or acute heart failure caused by fast AF
- If Yes
- Unstable
04Action Unstable: emergency synchronised DC cardioversion
Do not delay for anticoagulation. Sedate if possible.
- Adult, biphasic: first shock at least 200 J; increase if it fails
- Check OAC status; start anticoagulation as soon as possible unless bleeding or acute stroke
- OAC for at least 4 weeks after cardioversion; long term per stroke risk
- Shock fails or AF recurs: senior or cardiology help now
05Action Find and treat triggers
All patients (stable, or after cardioversion). Treat the cause before or with rate or rhythm control.
- Sepsis, fluid overload, cardiogenic shock
- Thyroid disease, alcohol, electrolyte disorder
- Bloods: electrolytes, renal and liver function, FBC, glucose/HbA1c, TSH
- Echocardiogram for LVEF and valves
06Warning Pre-excited AF (WPW): no AV-nodal blockers
Fast, irregular, broad QRS of varying width, or known WPW. Risk of VF.
- Do not give beta-blocker, diltiazem, verapamil, digoxin, adenosine or IV amiodarone
- Unstable: synchronised DC cardioversion
- Stable: DC cardioversion (OAC or TOE first if AF ≥24 h), or drug cardioversion only with cardiology advice
07Decision Pre-excited AF?
Broad, irregular QRS of varying width, or known WPW
- If Yes
- Pre-excited
08Outcome Pre-excited AF: cardioversion and urgent cardiology referral
Stable and AF ≥24 h or unknown onset: TOE-guided early cardioversion, or ≥3 weeks therapeutic OAC first; OAC ≥4 weeks after. Mechanical valve or moderate-severe mitral stenosis: warfarin, no DOAC. Refer for accessory pathway ablation. Assess stroke risk (CHA₂DS₂-VA).
If No- No pre-excitation
09Action No pre-excitation: rate control for all
Initial target resting HR <110 bpm. No diltiazem or verapamil if LVEF ≤40%, hypotension or acute HF. Acute decompensated HF: do not start a beta-blocker (oral or IV); IV amiodarone or digoxin (senior advice).
- LVEF >40%: beta-blocker, diltiazem, verapamil or digoxin (not a beta-blocker with diltiazem or verapamil unless closely monitored)
- LVEF ≤40% (not acute decompensated HF): beta-blocker and/or digoxin
- Unstable or severely reduced LVEF: IV amiodarone or digoxin may be used (senior advice). Amiodarone can cardiovert: check anticoagulation if AF ≥24 h
- Digoxin: check renal function first; lower dose in CKD. Asthma: avoid non-selective beta-blockers; none after severe bronchospasm
- Stricter target if symptoms persist
10Warning Acute stroke or brain bleed, valve disease, HCM or amyloidosis?
Acute ischaemic stroke, thrombolysis or thrombectomy, or intracranial bleed: stroke team sets OAC timing; do not start OAC or heparin yet. Active bleeding: stop anticoagulation and find the cause.
- Acute stroke: start OAC only after brain imaging and stroke team advice
- Mechanical valve or moderate-severe mitral stenosis: warfarin; no DOAC
- HCM or cardiac amyloidosis: oral anticoagulation whatever the CHA₂DS₂-VA score
11Action Stroke risk: CHA₂DS₂-VA score
ESC 2024 score; sex is not counted. 1 point each: heart failure, hypertension, diabetes, vascular disease, age 65-74. 2 points each: age ≥75, prior stroke, TIA or thromboembolism.
- C: Chronic heart failure (any LVEF), or LVEF ≤40% without symptoms (+1)
- H: Hypertension (+1)
- A₂: Age ≥75 years (+2)
- D: Diabetes (+1)
- S₂: Prior stroke, TIA or arterial thromboembolism (+2)
- V: Vascular disease (+1)
- A: Age 65-74 years (+1)
12Action Anticoagulation by CHA₂DS₂-VA score
Score ≥2: anticoagulate (after acute stroke, when the stroke team advises). Score 1: consider (shared decision). Score 0: not indicated. DOAC preferred; dose by each drug's criteria (renal function, age, weight). CrCl <30 mL/min or dialysis: specialist advice before any DOAC. Liver disease with coagulopathy, or Child-Pugh C: no DOAC. Other cirrhosis: specialist advice before any DOAC.
- Apixaban, dabigatran, edoxaban or rivaroxaban
- No DOAC: dabigatran if CrCl <30 mL/min; apixaban if CrCl <25 mL/min (AU PI) or dialysis; rivaroxaban or edoxaban if CrCl <15 mL/min or dialysis
- No reduced DOAC dose unless the drug's own criteria are met
- Do not use antiplatelet therapy instead of anticoagulation
- Do not use a bleeding score to withhold anticoagulation; treat modifiable bleeding risks
- Any score: anticoagulate around cardioversion (see rhythm control)
- Reassess stroke risk at each review
13Decision Symptoms persist, or rhythm control chosen?
Shared decision. Favours rhythm control: short AF history, suspected tachycardiomyopathy, non-dilated left atrium, patient preference.
- If Yes
- Rhythm control
14Action Symptoms or chosen: add rhythm control (keep rate control)
AF ≥24 h or unknown onset: ≥3 weeks therapeutic OAC, or TOE, before cardioversion. No flecainide or propafenone with CAD, HFrEF or severe LVH.
- AF <24 h: start anticoagulation (DOAC, LMWH or UFH) as soon as possible, then cardiovert (not in acute stroke or bleeding: senior advice)
- OAC for at least 4 weeks after cardioversion, even if CHA₂DS₂-VA 0 (optional only if sinus rhythm returns within 24 h of onset and there are no stroke risk factors); then long term per stroke risk
- Flecainide or propafenone: add beta-blocker, diltiazem or verapamil (avoids 1:1 flutter)
- No drug cardioversion with sinus node disease, AV block or QTc >500 ms
- HFrEF, CAD or severe LVH: amiodarone
- Stable recent-onset AF: waiting up to 48 h for spontaneous return is an option
- Catheter ablation: first-line option in paroxysmal AF, or if drugs fail or are not tolerated
- Consider rhythm control within 12 months of diagnosis in selected patients
15Action Treat risk factors and comorbidities (all patients)
Reduces AF recurrence and progression.
- Hypertension: treat
- Heart failure: diuretic if congested; SGLT2 inhibitor; HF therapy if LVEF reduced
- Diabetes: good glycaemic control
- Overweight or obese: lose 10% or more of body weight
- Alcohol: ≤3 standard drinks (≤30 g) per week
- Tailored exercise programme
- Sleep apnoea: do not screen with questionnaires alone
16Action Review and reassess
At 6 months, then at least yearly or when the patient's status changes.
- Symptoms (EHRA score) and heart rate
- Anticoagulant adherence and bleeding
- Renal function, FBC and weight for DOAC dosing
- Reassess stroke risk and comorbidities
17Decision Symptoms and heart rate controlled?
- If Yes
- Controlled
18Outcome Controlled: continue AF-CARE follow-up
Symptoms managed and stroke risk addressed.
If No- Not controlled
19Outcome Not controlled or complex: cardiology referral
Refractory symptoms, ablation candidate, HFrEF, or anticoagulation decision unclear.
If No- Rate control only
- Path rejoins step 15Shared downstream outcome
If No- Stable
- Path rejoins step 05Shared downstream outcome
Guideline Source
2024 ESC Guidelines for the management of atrial fibrillation
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- For non-pregnant adults. Pregnancy and children need specialist advice.
- Acute stroke or intracranial bleed: the stroke team sets anticoagulation timing.
- No drug doses: use the product information or a local protocol.
- Atrial flutter, post-operative AF and AF with acute coronary syndrome are not covered in detail.
- Simplified for common presentations; complex patients need specialist input.
Contraindicated Populations
pediatricpregnancy
Applicable Regions
EUUSAU
AU: The NHFA/CSANZ 2018 Australian AF guideline also uses CHA₂DS₂-VA. Edoxaban is not on the PBS.
EU: Uses the CHA₂DS₂-VA score per ESC 2024 (sex not counted).
US: ACC/AHA/ACCP/HRS 2023 uses CHA₂DS₂-VASc; consider local practice.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Atrial Fibrillation Management (ESC 2024 AF-CARE)?
The Atrial Fibrillation Management (ESC 2024 AF-CARE) is a management clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2024 ESC Guidelines for the management of atrial fibrillation.
What guideline is the Atrial Fibrillation Management (ESC 2024 AF-CARE) based on?
This algorithm is based on 2024 ESC Guidelines for the management of atrial fibrillation (DOI: 10.1093/eurheartj/ehae176).
What are the limitations of the Atrial Fibrillation Management (ESC 2024 AF-CARE)?
Known limitations include: For non-pregnant adults. Pregnancy and children need specialist advice.; Acute stroke or intracranial bleed: the stroke team sets anticoagulation timing.; No drug doses: use the product information or a local protocol.; Atrial flutter, post-operative AF and AF with acute coronary syndrome are not covered in detail.; Simplified for common presentations; complex patients need specialist input.. Individual patient factors may require deviation from these recommendations.
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