Kakar et al Given the substantial clinical burden of AF, its increasing frequency coupled with considerable health care costs, there is a compelling need for clinically directed evidence based clinical guidelines to improve its detection and management. This requirement is further justiﬁed by the observed wide variation in management and disagreement amongst UK consultants regarding what is considered to be the optimal management strategy for this highly complex condition. Guidelines for the management of AF The National Institute for Clinical Excellence (NICE [www. nice.org.uk]) is a UK-centered independent organization responsible for providing national guidance on the promo- tion of good health as well as the prevention and treatment of ill health. NICE commissioned the National Collaborating Centre for Chronic Conditions, based at the Royal College of Physicians, to develop a clinical guideline on AF for use in the NHS in England and Wales. This guideline offers clinical advice for the management of AF, based on the best-published evidence and expert consensus taking into account both patient choice and detailed cost efﬁcacy analy- sis. Furthermore, the guideline highlights key priorities for implementation. In this article, we present a brief overview of some of the key recommendations made in this document. Diagnosis of atrial ﬁbrillation The most common presenting symptoms of AF are dyspnea, palpitations, chest pain, dizziness, and fatigue (Levy et al 1999). In patients presenting with these symptoms, manual pulse palpation may determine the presence of an irregular pulse that warrants further investigation using a 12-lead ECG. The use of transthoracic echocardiography (TTE) should be limited to those in whom it is important for long- term management, such as younger patients, those being considered for a rhythm control strategy, those in whom the probability of underlying structural heart disease is high and where clinical risk stratiﬁcation for antithrombotic therapy is needed. Where diagnostic uncertainty remains in patients with suspected but undiagnosed PAF, 24-hour monitoring should be used if symptomatic paroxysms occur less than 24 hours apart. An event recorder should be reserved for where the paroxysms occur more than 24 hours apart. Treatment of atrial ﬁbrillation Changing trends The treatment of AF has undergone a paradigm shift over the last decade. The traditional strategy of predominant rhythm 110 control has been challenged by recent data comparing this to a more conservative rate control strategy. Results of the ﬁve primary rate versus rhythm control trials have shown that rate control is a non-inferior strategy to rhythm control in terms of mortality (Hohnloser et al 2001; Van gelder et al 2002, Wyse et al 2002; Carlsson et al 2003; Opolski et al 2003) or quality of life outcomes (Gronefeld et al 2003). However, in the largest of these studies (Wyse et al 2002), mortality was found to be higher for rhythm control in those with coronary heart disease, those without heart failure and those aged over 65 years old. In an additional rate versus rhythm control study by Okcun et al (2004), rhythm control was found to be preferable among patients with heart failure and dilated cardiomyopathy. However, there was signiﬁcant variation in the duration, intensity and quality of anticoagulation in the rhythm control arm of this study that may have affected the incidence of stroke and thromboembolism. The AFFIRM study suggested that whilst the strategy of rate control was associated with a trend to reduced mortality compared with rhythm control, subgroup analyses showed that actually successfully achieving sinus rhythm is associated with reduced mortality, which was offset by an increased mortality with antiarrhythmic drug and digoxin usage (Wyse et al 2002; Corley et al 2004). Of note, anticoagulation usage was an inde- pendent predictor of improved survival (Corley et al 2004). The strategies for rate control and rhythm control incor- porate different pharmacological regimes. Analysis of the available evidence demonstrates that different situations may warrant adoption of either rate control or rhythm con- trol strategy. A primary rate control strategy should be the preferred initial option in patients with persistent AF over 65 years, coronary artery disease, those with contraindications to antiarrhythmic drugs, patients unsuitable for cardioversion and among patients without congestive heart failure. In contrast, a primary rhythm control strategy should be the preferred initial option in the following patients with per- sistent AF: those who are symptomatic, younger, presenting for the ﬁrst time with lone AF, those with AF secondary to a treated/corrected precipitant and in those with congestive heart failure. The potential advantages and disadvantages of each strategy should be explained to patients. A section of patients with AF, who are resistant to the above management, may beneﬁt from interventional techniques such as pulmo- nary vein isolation (PVI) or a surgical Maze procedure. Rhythm control: the role of cardioversion Rhythm control may include electrical (ECV) and pharma- cological (PCV) cardioversion, as well as the use of surgical Vascular Health and Risk Management 2007:3(1)