Red flags
- Haemodynamic instability → DC cardioversion
- Pre-excited AF (WPW) → avoid AV blockers
- AF with acute HF or ischaemia
First steps
- ECG + rhythm strip
- Assess symptoms + haemodynamics
- TSH, U&E, echo
- CHA2DS2-VASc + HAS-BLED
Key investigations
- 12-lead ECG
- TFT, U&E, LFT, TnT, TSH
- Echo (structure, LA size, EF)
- Ambulatory monitoring if paroxysmal
Differentials
- Atrial flutter with variable block
- MAT (COPD)
- Sepsis-driven
Initial management
- Unstable → sync DC cardioversion
- Stable rate control: β-blocker or diltiazem (avoid CCB in HFrEF)
- Rhythm control if <48 h + stable: flecainide (structurally normal) or amiodarone; DC cardioversion
- Anticoag by CHA2DS2-VASc ≥2 M / ≥3 F: DOAC first-line
- Treat trigger (sepsis, hyperthyroid, ischaemia)
Referral
- Cardiology for rhythm control/ablation
- Stroke prevention clinic
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