Atrial fibrillation: NICE 2021 update and the focus on anticoagulation

ATRIAL FIBRILLATION DIAGNOSIS

Diagnosis of AF can be challenging as patients may be asymptomatic or have intermittent or non-specific symptoms and signs. For example, less than half of people with AF have palpitations. This may be of particular concern during the COVID-19 pandemic, with less opportunistic detection of AF and altered patterns of patients accessing health care. A Danish registry study reported a 47% decrease in the incidence of newly diagnosed AF between the first 3 months of 2020 compared with 2019.²

Although the sensitivity of manual pulse palpation to exclude permanent AF is good (93–100%), the positive predictive value of an irregular pulse is between 8–23%.³ The value of opportunistic screening for AF via pulse palpation is also uncertain, even among high-risk populations.⁴

The emphasis remains on using a 12-lead electrocardiogram (ECG) to diagnose AF. However, patients with intermittent symptoms may need ambulatory monitoring to detect paroxysmal AF. A variety of monitors are now available, including the more traditional external Holter-type devices, newer ‘patch’ monitors that can record for up to 2 weeks while allowing all activities of daily living with the device on, or event recorders, which are patient activated. Feasibility studies suggest many patients might be able to fit ambulatory monitors themselves at home and prefer to do so. This could enable more remote assessment, which may be particularly helpful during the COVID-19 pandemic or in patients with poor mobility. The …