referral criteria from primary care - atrial fibrillation (AF)

Last edited 04/2021 and last reviewed 04/2021

Urgent secondary care review is required if the patient is cardiovascularly compromised by atrial fibrillation.

Services for Patients with AF will vary in different locations. Some hospitals provide open access Echo and others provide specialist AF (often rapid access) clinics. Many patients with AF have heart failure and will be catered for in Heart Failure Clinics.

Indications for Emergency Rhythm Control (1)

Patients with ongoing atrial fibrillation at the time of initial evaluation, as confirmed by 12 lead electrocardiography, and

    • with very slow or rapid ventricular rates (typically <40 bpm and >150 bpm),
    • evidence of hemodynamic instability,
    • severe symptoms,
    • or decompensated heart failure

  • should be referred to the emergency department for stabilization and possible electrical cardioversion
  • in case of unknown duration of atrial fibrillation
    • cardioversion should be preceded by transesophageal echocardiography to rule out intracardiac thrombus
    • patients are required to be on anticoagulation for at least four weeks after electrical cardioversion to reduce the risk of thromboembolism

Rhythm control should be favored (1):

  • in the presence of significant atrial fibrillation related symptoms or presumed tachycardia induced cardiomyopathy
  • may also be preferable in younger (<65 years) patients with paroxysmal atrial fibrillation, as rate control alone is likely to result in progression to longstanding persistent atrial fibrillation over a period of time, which will later be more difficult to control and carries a risk of development of tachycardia induced cardiomyopathy

Indications for referral to specialty care (1)

  • initial rate control approach has failed or is not well tolerated

  • first line rhythm control approach is being considered

  • pre-existing or newly diagnosed concomitant structural heart disease, such as moderate or severe valvular dysfunction, amyloidosis, hypertrophic cardiomyopathy, or congenital heart defect

  • suspicion of significant coronary artery disease based on clinical history or objective testing

  • recent syncope

  • atrial fibrillation with slow ventricular rate (<40 bpm) or conversion pauses from atrial fibrillation to sinus rhythm exceeding 3 s or with associated symptoms

  • stroke, transient ischemic attack, or peripheral embolism at the time of initial presentation

  • young patients (<65 years of age) with new atrial fibrillation

  • complex anticoagulation decision making in atrial fibrillation patients at high risk of bleeding, such as those with cerebral amyloid angiopathy- consider left atrial appendage closure

  • patient or clinician preference

Additional suggested indications for cardiologist assessment include (2,3):

  • patient is suitable for cardioversion
  • frequent attacks of paroxysmal atrial fibrillation are an indication for referral. Also there is increased evidence for earlier use of ablation therapy in paroxysmal AF:
    • catheter ablation (2,3) in paroxysmal AF:
      • paroxysmal atrial fibrillation can be eliminated long term by catheter ablation in 80-90% of patients, although 30-40% require a repeat procedure
        • at 5%, the risk of major complications compares favourably with long term antiarrhythmic treatment
        • threshold for catheter ablation should be low, and the guidance recommend catheter ablation after one or more antiarrhythmic drug has failed (2)
        • in selected patients with paroxysmal AF and no structural heart disease left atrial ablation is reasonable as first-line therapy (3)