What is the management approach for atrial fibrillation (Afib) treatment?

From the Guidelines

The management of atrial fibrillation (Afib) involves a comprehensive approach focusing on rate control, rhythm control, stroke prevention, and addressing underlying causes, with the primary goal of reducing symptoms, preventing complications, and improving quality of life, as outlined in the 2024 ESC guidelines 1. The initial treatment typically includes rate control medications such as beta-blockers, calcium channel blockers, or digoxin. For rhythm control, antiarrhythmic drugs like amiodarone, flecainide, propafenone, or sotalol may be used.

• Key aspects of Afib management include:
  • Optimal treatment according to 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 1.
  • Shared care and patient-centered AF management with joint decision-making and a multidisciplinary team 1.
  • Education for patients, family members, caregivers, and health-care professionals to aid shared decision-making 1.
  • Diagnosis of clinical AF requires confirmation on an ECG device to initiate risk stratification and AF management 1.
  • Initial evaluation includes medical history, assessment of symptoms and their impact, blood tests, echocardiography/other imaging, patient-reported outcome measures, and risk factors for thromboembolism and bleeding 1.
  • Comorbidities and risk factors should be thoroughly evaluated and managed to avoid recurrence and progression of AF, improve success of AF treatments, and prevent AF-related adverse outcomes 1.
  • Focus on conditions associated with AF, including hypertension, heart failure, diabetes mellitus, obesity, obstructive sleep apnea, physical inactivity, and high alcohol intake 1.
  • 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.
  • Oral anticoagulants are recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism, with DOACs preferred over VKAs except in patients with mechanical heart valves and mitral stenosis 1.
  • Choice of anticoagulant, dose/range of anticoagulant, and switching anticoagulants should be based on individual patient factors and guidelines 1.
  • Bleeding risk should be managed by addressing modifiable bleeding risk factors, and bleeding risk scores should not be used to decide on starting or withdrawing anticoagulants 1.
  • Antiplatelet therapy should be avoided in combination with anticoagulants, unless the patient has an acute vascular event or needs interim treatment for procedures 1.
  • Rate control therapy should use beta-blockers, digoxin, or diltiazem/verapamil as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms 1.
  • Rhythm control should be considered in all suitable AF patients, with explicit discussion of potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity 1.
  • Safety first, keeping safety and anticoagulation in mind when considering rhythm control, with delay of cardioversion and provision of at least 3 weeks of anticoagulation beforehand if AF duration >24 h, and consideration of toxicity and drug interactions for antiarrhythmic therapy 1.
  • Cardioversion, catheter ablation, and endoscopic or hybrid ablation should be considered based on individual patient factors and guidelines 1.
  • Dynamic evaluation and reassessment of therapy should be performed periodically to address new modifiable risk factors and improve quality of life 1. The management of Afib should be individualized, taking into account the patient's specific needs, comorbidities, and risk factors, with the goal of improving quality of life and reducing morbidity and mortality, as supported by the 2024 ESC guidelines 1.

From the FDA Drug Label

In patients with non-valvular AF, anticoagulate with warfarin to target INR of 2.5 (range, 2.0 to 3.0). In patients with non-valvular AF that is persistent or paroxysmal and at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, or 2 of the following risk factors: age greater than 75 years, moderately or severely impaired left ventricular systolic function and/or heart failure, history of hypertension, or diabetes mellitus), long-term anticoagulation with warfarin is recommended In patients with non-valvular AF that is persistent or paroxysmal and at an intermediate risk of ischemic stroke (i.e., having 1 of the following risk factors: age greater than 75 years, moderately or severely impaired left ventricular systolic function and/or heart failure, history of hypertension, or diabetes mellitus), long-term anticoagulation with warfarin is recommended.

The management approach for Atrial Fibrillation (Afib) treatment involves anticoagulation with warfarin, targeting an INR of 2.5 (range, 2.0 to 3.0). Long-term anticoagulation is recommended for patients with non-valvular Afib who are at high or intermediate risk of ischemic stroke. Key factors to consider when determining the risk of stroke include:

• Age greater than 75 years
• Moderately or severely impaired left ventricular systolic function and/or heart failure
• History of hypertension
• Diabetes mellitus
• Prior ischemic stroke, transient ischemic attack, or systemic embolism 2

From the Research

Afib Management Approach

The management of atrial fibrillation (Afib) involves two primary tenets: prevention of stroke and systemic embolism, and symptom control through either rate or rhythm control strategies 3.

Rate Control Strategy

• Rate control involves using medications such as beta-blockers, non-dihydropyridine calcium channel blockers, or digoxin to control symptoms while allowing Afib to persist 4, 5.
• This approach is often the initial strategy used for symptom control in Afib due to the safe nature of these medications.
• Rate control can be achieved through pharmacologic or nonpharmacologic options, and the choice of treatment depends on the individual patient's clinical status and comorbidities 6.

Rhythm Control Strategy

• Rhythm control involves cardioversion and treatment with antiarrhythmic medications to maintain sinus rhythm 4, 5.
• This approach may be preferred for patients newly diagnosed with Afib, as newer data suggest it may lead to a reduction in major adverse cardiovascular events 3.
• Rhythm control can be achieved through pharmacologic or nonpharmacologic options, including catheter ablation for symptomatic patients whose Afib is refractory to standard treatment 5.

Prevention of Stroke and Systemic Embolism

• The CHA2DS2-VASc score should be used to predict the risk of stroke for patients with Afib 5.
• Patients with nonvalvular Afib and a history of stroke or transient ischemic attack, or CHA2DS2-VASc scores of 2 or greater, should be treated with warfarin or novel oral anticoagulants 5.
• Patients with valvular Afib should be treated with warfarin 5.

Comparison of Rate and Rhythm Control Strategies

• The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study compared rate and rhythm control strategies and found that rhythm control did not reduce the risk of death or serious cardiovascular events, but caused more adverse events than rate control 4, 7.
• Other studies have confirmed the risk of serious adverse effects associated with rhythm control, including severe arrhythmia and adverse thyroid and pulmonary effects 7.