Medical Therapy - Atrial Fibrillation
Stroke risk and anticoagulation
Congestive Heart Failure | 1 |
Hypertension | 1 |
Age 75+ | 2 |
Age 65-74 | 1 |
Diabetes | 1 |
Prior stroke/TIA/thromboembolic event | 2 |
Vascular disease | 1 |
Female gender | 1 |
The implications of the score vary according to gender, as follows:
Score | Male | Female |
0 | Do not consider anticoagulation | Do not consider anticoagulation |
1 | Consider anticoagulation | If point awarded for gender alone, do not consider anticoagulation |
2 | Prescribe anticoagulant | Consider anticoagulant |
3 | Prescribe anticoagulant | Prescribe anticoagulant |
3+ | Prescribe anticoagulant | Prescribe anticoagulant |
Before prescribing an anticoagulant, doctors must take into account a patient’s risk of sustaining a serious bleed whilst on the medication, and balance this against the potential benefit from anticoagulation. There is a useful scoring system, the HAS-BLED, which helps them to do so, with a point being allocated for each of the following:
Hypertension | Uncontrolled BP, systolic (top) reading >160 |
Abnormal renal and liver function | Identified on blood testing |
Stroke | Prior history of stroke or TIA |
Bleeding | History of major bleed |
Labile INR | Difficulty maintaining target in warfarin users |
Elderly | Age >65 years |
Drugs or alcohol | Heavy alcohol consumption or use of medication predisposing to bleeding |
Doctors will then compare the two scores to be sure that the benefit to starting an anticoagulant outweighs any potential bleeding risk.
Direct Oral anticoagulants (DOACs)
Rate and rhythm control
When in atrial fibrillation the heart can sometimes beat very quickly, which may be associated with symptoms such as palpitations or breathlessness. Even if a patient is not symptomatic, doctors try to keep the heart rate to below 90 beats per minute, since the pumping action of the heart tends not to be so effective at sustained rates above this level. There are a number of drugs available which can be used to slow the heart rate in atrial fibrillation, the most common types being beta blockers such as bisoprolol, and calcium channel blockers such as verapamil and diltiazem. Digoxin, which is actually extracted from the foxglove plant, is sometimes used when the other drugs cannot be.
In certain patients, particularly those who are symptomatic from their AF despite medication or in those where it is clear that the change in heart rhythm is causing a decline in heart function, it is appropriate to try to restore sinus rhythm. In the first instance a patient may be prescribed an anti-arrhythmic medication such as flecainide, sotalol, or amiodarone. If these drugs are successful in restoring sinus rhythm, this is known as chemical cardioversion, although when doctors talk about cardioversion, they are usually referring to the day case hospital procedure.

Related links:
Symptoms - Palpitations, Dizzy Spells and
Blackouts
Palpitations are a common symptom that may or may not signify an important underlying heart problem. Read more
Tests - ECG Monitoring
There are several different types of ECG monitoring, chosen based on symptoms or the condition in question. Read more
Tests - EP Study
There are many types of abnormal heart rhythm, some minor, some troublesome and some posing a risk to life. Read more
Conditions - Atrial Fibrillation
Atrial fibrillation (often abbreviated to “AF”) is a very common heart rhythm disturbance, affecting over a million people in the UK. Read more
Treatments - Ablation
The role of ablation in the treatment of various abnormal heart rhythms has evolved over the last two decades and now has an established place in the management of various arrhythmias, the most common of which is atrial fibrillation. Read more