Atrial fibrillation is a frequent presentation in emergency departments and cardiology clinics, yet the transition from acute recognition to durable stroke prevention remains uneven. In Saudi Arabia, the rising burden of cardiometabolic disease, ageing, renal impairment and fragmented follow-up creates a setting in which anticoagulation decisions are clinically important and operationally fragile. This review examines anticoagulation gaps, stroke-risk assessment and guideline-based care for adults with atrial fibrillation managed in Saudi emergency and cardiology settings. A structured narrative method was used to synthesise international guidelines, contemporary emergency-care evidence and Saudi literature published from 2020 to 2025. The review identifies recurring gaps: incomplete documentation of CHA2DS2-VASc or CHA2DS2-VA scores, uncertainty around direct oral anticoagulant dosing, persistent use of non-anticoagulant antiplatelet therapy for stroke prevention, delayed initiation after emergency discharge, limited renal-function reassessment, and variable cardiology follow-up. These gaps are not merely prescribing issues; they reflect competing priorities at presentation, inconsistent ownership between emergency physicians and cardiology teams, patient concerns about bleeding, and limited structured counselling. Guideline-based care should begin at first contact, with electrocardiographic confirmation, haemodynamic stabilisation, systematic stroke and bleeding risk assessment, renal and hepatic review, medication reconciliation, shared decision-making and a defined follow-up appointment before discharge. A Saudi model should combine emergency pathways, pharmacist-supported anticoagulant initiation, cardiology review for rhythm strategy, and quality indicators that track eligible anticoagulation, dose correctness and early review. Strengthening this pathway could reduce preventable stroke, avoid unnecessary admission and improve continuity for patients who currently move between episodic acute care and chronic cardiovascular management.