Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide with a trend of increasing morbidity and prevalence. It usually links to a high disability and mortality rate. Stroke is the most important and severe complication of AF, as a core strategy to prevent it, anticoagulation therapy is recommended to reduce the risk of stroke events. However, management risks including poor treatment adherence, individual difference and bleeding risk can′t be ignored. In the western countries, they have successively established a nurse-led integrated chronic care program for patients with atrial fibrillation. We can use it to guide our future work. Anticoagulation therapy is a long-term managing process. To integrate the existing medical resources, nurses must give their full play to access the deep needs and guide them to learn the core skills of management, thus improving the adherence to anticoagulation therapy.