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Atrial Fibrillation (AF)

Also known as: AF · AFib · irregularly irregular pulse

The commonest sustained arrhythmia — an irregularly irregular pulse with no P waves on ECG. The two key harms are stroke (thromboembolism) and heart failure; management is rate/rhythm control plus stroke-risk-based anticoagulation.

Source · Reviewed 2026-08-15 · v1.0— AI-assisted draft — verify against the cited guideline before clinical use.

⚕️ Education only — not medical advice. Verify against the latest official guideline and your local protocol; confirm every drug dose against the cited source before clinical use.

Who gets it

Older adults; hypertension, ischaemic/valvular/structural heart disease, heart failure, thyrotoxicosis, alcohol, sepsis/infection and the post-operative state.

Red flags — escalate / refer

Haemodynamic instability — hypotension, ischaemic chest pain, pulmonary oedema or reduced consciousness → urgent synchronised DC cardioversion.

Work-up / diagnosis

1ECG to confirm; identify reversible causes (thyroid function, electrolytes, infection, alcohol) and assess for structural disease with echocardiography.
2Establish the onset time (relevant to cardioversion) and assess stroke risk (e.g., CHA₂DS₂-VASc) and bleeding risk.

Management — overview

Unstable → emergency synchronised cardioversion.
Stable: choose rate control (beta-blocker or a rate-limiting calcium blocker, digoxin as an adjunct) or rhythm control (electrical/chemical cardioversion, anti-arrhythmics, ablation) — treat the underlying cause either way.
Anticoagulate based on stroke-risk score (a DOAC or warfarin), NOT on symptoms or rhythm; this decision is separate from rate/rhythm control.
For cardioversion when AF has been present >48 h or the duration is unknown, ensure adequate anticoagulation (or exclude atrial thrombus) first.

In-depthFull dosing & advanced protocol

Drug dosing

Rate-control agent (beta-blocker or diltiazem/verapamil; digoxin adjunct)

Ventricular rate control

Adult dose: Titrated to target rate — per protocol
Route: Oral / IV

Caution: Avoid combining a beta-blocker with verapamil/diltiazem IV (bradycardia/block); caution in heart failure.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Oral anticoagulant (DOAC or warfarin)

Stroke prevention, guided by risk score

Adult dose: DOAC at licensed dose, or warfarin to target INR — per protocol
Route: Oral

Caution: Weigh bleeding risk; dose-adjust in renal impairment; warfarin needs INR monitoring.

WHOWHO Model List of Essential Medicines (electronic EML) (2025 (24th)) ↗

Rate vs rhythm, and the separate anticoagulation decision

For most patients rate control is a reasonable first strategy; rhythm control is favoured in younger, symptomatic, or new-onset AF.
Anticoagulation is driven by the stroke-risk score, independent of whether sinus rhythm is restored.
Cardioversion of AF >48 h (or unknown duration) requires ≥3 weeks of anticoagulation beforehand or a transoesophageal echo to exclude thrombus, and anticoagulation afterwards.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

References

Guidelines change. If something here is out of date, tell us — we keep these current.

🚩 Report outdated / suggest update

More protocols

Acute Coronary Syndrome (incl. STEMI)Acute myocardial ischaemia — STEMI, NSTEMI or unstable angina. STEMI needs immediate reperfusion: “time is muscle”.Acute Heart FailureRapid onset or worsening of heart-failure symptoms — breathlessness, orthopnoea and oedema, often with pulmonary congestion. Relieve congestion and find the trigger.Hypertensive EmergencySevere blood-pressure elevation (usually >180/120 mmHg) WITH acute target-organ damage (brain, heart, kidney, retina). Needs controlled IV lowering — distinct from asymptomatic severe hypertension ('urgency').

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👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

💊 Drug dosing

Rate-control agent (beta-blocker or diltiazem/verapamil; digoxin adjunct)

Oral anticoagulant (DOAC or warfarin)

📈 Rate vs rhythm, and the separate anticoagulation decision

📚 References

More protocols

👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

💊 Drug dosing

Rate-control agent (beta-blocker or diltiazem/verapamil; digoxin adjunct)

Oral anticoagulant (DOAC or warfarin)

📈 Rate vs rhythm, and the separate anticoagulation decision

📚 References

More protocols

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Drug dosing

Rate vs rhythm, and the separate anticoagulation decision

References

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Drug dosing

Rate vs rhythm, and the separate anticoagulation decision

References