Atrial Fibrillation (AF) Care Staff Guide: Stroke Risk and Anticoagulants

Atrial fibrillation, often shortened to AF, is the most common type of heart rhythm problem seen in older people. The heartbeat becomes irregular and often fast because of a fault in the heart's electrical system. Many people have it for years without knowing. The main danger is not the palpitations but the increased risk of blood clots and stroke, which is why recognition and the right treatment matter so much.

This guide explains what AF is, the symptoms, how it is found and treated, why anticoagulant medicines are so important, and what care staff can do to support residents. It does not replace the advice of the resident's GP or cardiology team.

What is atrial fibrillation?

According to the NHS, AF is a heart rhythm problem in which the heartbeat is not steady. Episodes can come and go (paroxysmal), continue until treated (persistent) or be ongoing (permanent). Some people have no symptoms at all and the condition is found during a routine check.

Symptoms and risk factors

The NHS lists these possible symptoms:

• an irregular pulse or noticeable palpitations
• a heart rate above 100 beats per minute
• tiredness and reduced ability to do usual activities
• chest pain or tightness
• breathlessness
• feeling light-headed or dizzy

Risk factors include being 55 or over, being male, overweight or obesity, smoking and certain medicines. AF can also be linked with high blood pressure, heart failure, valve problems, a previous heart attack, chronic kidney disease, an overactive thyroid, diabetes and sleep apnoea. In care homes, residents often have several of these conditions together, so a new irregular pulse or unexplained tiredness should not be dismissed as "just age".

How AF is found

NICE guideline NG196 advises that a manual pulse check should be done when AF is suspected, for example in people with breathlessness, palpitations, dizziness or fainting, chest discomfort, or stroke or TIA. If the pulse is irregular, a 12-lead ECG is performed to confirm the diagnosis. Care staff who take pulse readings as part of observations should report an irregular or newly fast pulse rather than simply recording it.

Why stroke risk matters

The NHS lists blood clots, stroke and heart failure as complications of AF. A clot can form in the heart because blood does not move normally, then travel to the brain. This is why the signs of stroke are essential knowledge for anyone caring for a person with AF. Face drooping, arm weakness and speech problems are emergencies requiring a 999 call, and our guide to stroke recognition and the FAST test explains the steps to take.

The NHS says to call 999 if a fast or irregular heartbeat comes with chest pain, breathlessness, sweating, nausea, fainting or dizziness, a severe headache, weakness or numbness on one side, blurred vision or sight loss, or confusion or difficulty speaking. For other concerns, such as palpitations that persist or worsen, or treatment that does not seem to be working, a GP appointment is appropriate.

Treatment

The NHS describes treatment as aiming to control symptoms and reduce complications, as there is currently no cure. It can include:

• medicines to control heart rate and rhythm, such as beta blockers
• anticoagulant medicines to reduce the risk of clots and stroke
• procedures such as cardioversion, ablation, or fitting a pacemaker or ICD
• treating an underlying condition or stopping a medicine that is causing AF

NICE recommends rate control as the first-line strategy for most people, using a standard beta blocker or a rate-limiting calcium-channel blocker, and says rhythm control may be considered if symptoms continue or rate control fails.

Anticoagulants: the key medicine for stroke prevention

NICE advises using the CHA2DS2-VASc score to assess stroke risk. It recommends offering a direct-acting oral anticoagulant to people with a score of 2 or above, taking bleeding risk into account. Apixaban, dabigatran, edoxaban and rivaroxaban are named as options. NICE also states that aspirin alone should not be offered solely for stroke prevention in AF.

Two points from NICE are particularly relevant in care homes. First, anticoagulation should not be withheld solely because of a person's age or their risk of falls. Second, bleeding risk should be assessed using the ORBIT score, and people should be offered monitoring and support to reduce modifiable bleeding risks. People taking an anticoagulant should be reviewed at least annually, or sooner if relevant events occur.

In practice, care staff can help by:

• giving anticoagulants at the right time, every time, and recording any missed or refused dose and reporting it
• never stopping or pausing an anticoagulant without clinical advice
• reporting bleeding, easy bruising or any fall, especially a head injury, to a senior colleague or clinician promptly
• checking that appointments for anticoagulant reviews take place

Our guide to anticoagulant safety for warfarin and DOACs covers the medicine-specific points in more detail, and falls prevention in care homes explains how to reduce risk while still supporting independence.

Supporting residents day to day

Good support combines observation with communication. Learn the resident's usual pulse pattern and energy level so changes stand out. Allow rest during the day for people who tire easily, and give clear explanations about why medicines matter, since a resident who feels well may question why they still need an anticoagulant. Notice anxiety about palpitations, and share concerns with the clinical team. Involve the person in decisions about their care wherever possible.

Frequently asked questions

Can someone with AF have no symptoms?

Yes. The NHS says some people have no symptoms and AF is found during routine checks.

Does AF always need an anticoagulant?

Not always. The decision depends on stroke risk and bleeding risk, assessed by clinicians using tools such as CHA2DS2-VASc and ORBIT. Care staff should never decide this themselves.

Is a history of falls a reason to avoid anticoagulants?

NICE says anticoagulation should not be withheld solely because of age or falls risk. The decision rests with the prescriber and the resident.

Developing your skills

Knowing the basics of common heart conditions helps staff notice change early and communicate clearly with clinicians. Explore our CPD training for care staff to keep your knowledge up to date. This article draws on the NHS atrial fibrillation page (reviewed January 2025) and NICE guideline NG196.