Atrial fibrillation
Separate formulary recommendations are available for reversal agents in cardiovascular conditions.
DOACs are not recommended in AF patients with mechanical heart valves or moderate to severe mitral valve stenosis. Apixaban is the first line choice of DOAC.
First choice in AF patients with mechanical heart valves or moderate-to-severe mitral valve stenosis.
Prescribing Notes:
- Consult local/national guidance for appropriate AF stroke risk calculator.
- Apixaban is the DOAC of choice. Alternative DOACs may be considered if apixaban unsuitable.
- The medications listed above are provided as guidance for new patients. Any available local guidelines should also be consulted.
- For more information refer to National Patient Safety Alert on the inappropriate anticoagulation of patients with a mechanical heart valve.
- When warfarin or DOAC therapy is initiated anti-platelet therapy is normally discontinued, except on specialist advice by cardiology to continue, this will be communicated in individual patient correspondence.
History Notes
27/05/2026
Regional formulary chapter launched.
Persistent or permanent atrial fibrillation in patients who are sedentary (do no or very little physical exercise).
Atenolol is an alternative choice and should only be used when initiating a beta-blocker.
Prescribing Notes:
- Beta-blockers may cause bronchospasm; use with caution and under specialist supervision in patients with a history of asthma.
History Notes
27/05/2026
Regional formulary chapter launched.
To maintain sinus rhythm post cardioversion. It is not for persistent or permanent atrial fibrillation.
In recurrent paroxysmal atrial fibrillation to restore sinus rhythm (known as ‘pill in the pocket’ therapy).
Maintenance of sinus rhythm.
Prescribing Notes:
- Patients receiving amiodarone should avoid exposure of the skin to direct sunlight or sun lamps; a sunscreening product providing a minimum of SPF 30 should be applied if amiodarone is prescribed. See sunscreening recommendations in the Skin chapter of the formulary.
- Class III antiarrhythmics including amiodarone and sotalol may cause QT prolongation and atypical VT (torsades de pointes); they should be given with extreme caution with drugs known to prolong the QT interval. Consult BNF or QT prolongation website for full information.
History Notes
27/05/2026
Regional formulary chapter launched.