Executive summary
- Detect: Pulse palpation -> 12-lead ECG. (Watch devices: confirm with ECG).
- Assess: Stroke risk (CHA2DS2-VASc) vs Bleeding risk (ORBIT).
- Treat: Anticoagulation (DOAC > Warfarin) + Rate Control (Beta-blocker).
Stroke Prevention (The Decision)
- CHA2DS2-VASc Score:
- Score 2+: Offer anticoagulation.
- Score 1 (Males): Consider anticoagulation.
- Score 0 (Males) / 1 (Females): No treatment needed.
- Bleeding Risk: Use ORBIT score (preferred over HAS-BLED). High risk is not a contraindication; it is a prompt to modify risk factors (BP, alcohol, NSAIDs).
Therapy Choices
- Anticoagulation:
- 1st Line: DOAC (Apixaban 5mg bd, Edoxaban 60mg od, Rivaroxaban 20mg od, or Dabigatran).
- Dose Adjust: Check renal function (Creatinine Clearance) and weight. e.g., Apixaban 2.5mg bd if 2 of: Age ≥80, Wt ≤60kg, Cr ≥133.
- 2nd Line: Warfarin (only if DOAC contraindicated or mechanical valves). Target INR 2.5.
- Rate Control (First line strategy):
- Standard: Beta-blocker (e.g., Bisoprolol 2.5mg od -> titrate to 10mg) OR Rate-limiting CCB (Diltiazem/Verapamil).
- Warning: Do NOT combine Beta-blocker + Verapamil/Diltiazem in primary care (risk of complete heart block).
- Sedentary: Digoxin monotherapy (only if non-active).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.