Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Confirmed AF PathwaySuspected AF Pathway

Atrial Fibrillation (AF)

Pathway published: April 2023.
Next review date: April 2025. 

 Suspected Atrial Fibrillation

Either incidental finding on ECG or clinical finding of irregularly irregular pulse

  • Conduct cardio vascular examination, assess for red flags (see pathway for details)
  • Perform ECG

    The following patients should be referred to emergency care
  • Pulse >150 beats/minute and/or low BP (systolic <90mmHg)
  • Loss of consciousness, chest pain, severe shortness of breath
  • Complication of AF (stroke, TIA, acute CCF)

If ECG does not show AF:

  • Sinus rhythm but paroxysmal AF still suspected à consider differentials and ambulatory monitoring (see pathway for details)
  • Non-AF arrhythmia identified à consider if cardiology referral appropriate

If ECG confirms AF:

Persistent AF likely (lasts longer than 7 days or requires termination by cardioversion)

  • Assess in primary care for underlying causes (see pathway for details)
  • Start symptomatic management in primary care, even if referred to cardiology
  • Consider if rate or rhythm control needed (see pathway for details)
  • Consider risks and benefits of anticoagulation
  • Consider need for echo
  • Consider referral to cardiology (see pathway for referral criteria and advice)
  • Review medication and continue to reduce stroke risk

Paroxysmal AF likely (usually terminates within 48h)

  • Referral to cardiology recommended for this group (see pathway for details)
  • Consider risks and benefits of anticoagulation
  • Consider starting rate control medication whilst waiting for cardiology appointment (see pathway for details)