From the Guidelines
For an atrial fibrillation patient presenting with palpitations, the management approach should prioritize the AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment, as recommended by the 2024 ESC guidelines 1. The initial evaluation should include a thorough medical history, assessment of symptoms and their impact, blood tests, echocardiography/other imaging, patient-reported outcome measures, and risk factors for thromboembolism and bleeding. Key considerations in the management of atrial fibrillation include:
- Assessing the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score, with reassessment at periodic intervals to assist in decisions on anticoagulant prescription 1
- Starting oral anticoagulants for all eligible patients, except those at low risk of incident stroke or thromboembolism, with a preference for DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) over VKAs (warfarin and others) 1
- Using rate control therapy with beta-blockers, digoxin, or diltiazem/verapamil as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms 1
- Considering rhythm control in all suitable AF patients, explicitly discussing with patients all potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity 1 Additional considerations include:
- Obtaining basic blood work including electrolytes, CBC, and thyroid function tests
- Assessing for underlying causes such as infection, hyperthyroidism, or alcohol use
- Educating the patient on recognizing symptoms and when to seek medical attention
- Periodically reassessing therapy and giving attention to new modifiable risk factors that could slow/reverse the progression of AF, increase quality of life, and prevent adverse outcomes 1
From the Research
Management Approach for Atrial Fibrillation (AFib) with Palpitations
The management approach for a patient with atrial fibrillation (AFib) presenting with palpitations involves either rate control or rhythm control strategies.
- Rate control is often considered the initial treatment approach, especially for patients with heart failure, as it can help alleviate symptoms and improve quality of life 2, 3, 4, 5, 6.
- The choice of rate control medication depends on the patient's symptoms, clinical characteristics, and presence of underlying heart disease 3, 5, 6.
- Beta blockers, non-dihydropyridine calcium channel blockers, and digoxin are commonly used rate control medications, with beta blockers being a preferred option for stabilized heart failure and digoxin for unstabilized forms 5, 6.
- Atrioventricular node ablation with pacemaker insertion is considered a last resort for rate control, but may be an option for patients with atrial fibrillation treated with cardiac resynchronization therapy 6.
Rhythm Control Strategy
- Rhythm control strategy may be considered for patients with highly symptomatic AFib, despite adequate rate control 2, 4.
- Amiodarone is the only recommended antiarrhythmic drug for rhythm control in patients with heart failure, and can be used for both rhythm and rate control of AFib 2.
- Catheter ablation (CA) can be applicable for AFib associated with heart failure, but the results of CA are closely associated with the clinical and electrophysiological characteristics of each patient, as well as the experience with this procedure in each institution 2.
Assessment of Efficacy
- The clinical target of rate control should be a ventricular rate below 80-90 bpm at rest, with assessment of efficacy including exercise testing and 24-hour Holter monitoring 5.
- Rate control is considered a valid alternative to rhythm control, with recent prospective trials showing similar benefits in terms of quality of life and long-term mortality 5.