How would you manage a patient with atrial fibrillation (AF) and unstable angina?

From the Guidelines

Management of a patient with atrial fibrillation (AF) and unstable angina requires immediate stabilization with intravenous beta-blockers or calcium channel blockers for rate control, and anticoagulation with unfractionated heparin or low molecular weight heparin, along with antiplatelet therapy for unstable angina. The initial approach should focus on assessing hemodynamic stability and providing supplemental oxygen if needed. For unstable angina, administer aspirin (325 mg loading dose, then 81 mg daily), plus a P2Y12 inhibitor such as ticagrelor (180 mg loading dose, then 90 mg twice daily) or clopidogrel (600 mg loading dose, then 75 mg daily) 1. For AF rate control, use intravenous beta-blockers such as metoprolol (5 mg IV every 5 minutes, up to 3 doses) or calcium channel blockers like diltiazem (0.25 mg/kg IV over 2 minutes, followed by infusion if needed), as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. Avoid digoxin in acute settings due to delayed onset. For long-term management, oral anticoagulation with a direct oral anticoagulant (DOAC) like apixaban (5 mg twice daily) or warfarin (target INR 2-3) is necessary to prevent thromboembolism, with the choice of anticoagulant guided by the patient's individual risk of thromboembolism and bleeding 1. Early cardiac catheterization should be considered to address the underlying coronary disease. Key considerations include:

• Assessing the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score 1
• Managing comorbidities and risk factors to avoid recurrence and progression of AF, improve success of AF treatments, and prevent AF-related adverse outcomes 1
• 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 of Atrial Fibrillation with Unstable Angina

• The management of atrial fibrillation (AF) with unstable angina involves controlling the heart rate, preventing thromboembolic events, and treating the underlying heart disease 2, 3, 4, 5, 6.
• The treatment aims are to reduce symptoms, prevent embolism, and prevent deterioration of the underlying heart disease 2.
• Heart rate control can be achieved using digoxin, beta-blockers, diltiazem, or verapamil, while rhythm control can be achieved using amiodarone, disopyramide, flecainide, quinidine, or sotalol 2.
• However, rhythm control may not reduce the risk of death or serious cardiovascular events, and may cause more adverse events than rate control, especially in patients over 65 or with coronary heart disease 2.
• Beta-blockers, such as metoprolol, can be effective in maintaining sinus rhythm and controlling the ventricular rate during atrial fibrillation, and may be considered as first-line agents in the management of patients with AF 3.
• The choice of antiarrhythmic drug depends on the patient's underlying heart disease, the presence of structural heart disease, and the risk of proarrhythmic events 5, 6.
• In patients with unstable angina, the use of antiarrhythmic drugs such as amiodarone or sotalol may be considered, but the risk of proarrhythmic events and other adverse effects must be carefully weighed against the potential benefits 5, 6.
• Cardioversion may be considered in patients with recent-onset AF, but the risk of thromboembolic events must be carefully assessed and anticoagulation therapy considered 4, 5, 6.
• The management of AF with unstable angina requires a comprehensive approach that takes into account the patient's underlying heart disease, the presence of structural heart disease, and the risk of proarrhythmic events, and involves a combination of heart rate control, rhythm control, anticoagulation, and treatment of the underlying heart disease 2, 3, 4, 5, 6.

Treatment Options

• Digoxin: can be used to control the heart rate, but may not be effective in restoring sinus rhythm 2, 4.
• Amiodarone: can be used to restore and maintain sinus rhythm, but may have potentially serious adverse effects 2, 5, 6.
• Beta-blockers: can be used to control the heart rate and maintain sinus rhythm, and may be considered as first-line agents in the management of patients with AF 3.
• Cardioversion: may be considered in patients with recent-onset AF, but the risk of thromboembolic events must be carefully assessed and anticoagulation therapy considered 4, 5, 6.