• Check for ongoing symptoms (at rest or with exercise) and assess heart rate.
• If the person is taking rate-control treatment and has persistent symptoms or a fast heart rate, consider increasing the drug dose (if they are not taking the maximum dose), combining drug treatments (if this has not already been done), or referring to a cardiologist.
• If the person is taking rhythm-control treatment and has recurring or persistent symptoms, refer back to a cardiologist for further assessment (for example for development of persistent atrial fibrillation [AF] or failed rhythm-control treatment).
• Assess stroke and cardiovascular disease (CVD) risk.
• If the person is not taking warfarin, reassess risk of stroke if they develop diabetes, hypertension, or cardiovascular disease, or when they reach 65 and 75 years of age.
• If the person is taking warfarin, reassess risk of bleeding (such as risk of falling).
• For information on how to assess CVD risk, see the CKS topic on CVD risk assessment and management.
• Check for complications of AF and assess blood pressure.
• Identify and manage existing heart failure or hypertension — see the CKS topics on Heart failure - chronic and Hypertension - not diabetic.
• Review the person's medication.
• Check compliance, and identify and manage drug interactions and complications (such as dyspepsia with aspirin).
• Give advice on known drug interactions and which drugs should be avoided with aspirin or warfarin (see Prescribing information).
• Provide information on AF.
• Provide written information (if this has not already been given).
• Explain when to seek further medical advice (such as worsening symptoms).
• For more information on patient education and support groups, see www.atrialfibrillation.org.uk.

Heart rate control

• The National Institute for Health and Clinical Excellence recommends that resting heart rate should be controlled to less than 90 beats per minute, and that heart rate on exercise should be controlled to less than 110 beats per minute in people who are inactive or 200 beats per minute minus their age in active people [NICE, 2006].
• A consensus statement from the Royal College of Physicians of Edinburgh suggests a target resting heart rate of less than 90 beats per minute and less than 180 beats per minute during exercise [RCGP, 1999].
• An international guideline states that criteria for rate control vary with age and suggests that ventricular rate should be controlled between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise [Fuster et al, 2006b].
• In clinical practice, the target heart rate during exercise may need to be adjusted depending on the level of exercise the person can manage. For example, a rate of 170 beats per minute is inadequate rate control if the person has only walked up the corridor.

• These recommendations are based in part on the National Institute for Health and Clinical Excellence (NICE) guideline Atrial fibrillation: national clinical guideline for management in primary and secondary care [National Collaborating Centre for Chronic Conditions, 2006], the Institute for Clinical Systems Improvement health care guideline Atrial fibrillation [ICSI, 2008], and a guideline produced jointly by US and European specialist groups [Fuster et al, 2006a].