What is the management of acute atrial fibrillation?

From the Guidelines

The management of acute atrial fibrillation should follow the AF-CARE pathway, which includes comorbidity and risk factor management, avoidance of stroke and thromboembolism, reduction of symptoms by rate and rhythm control, and evaluation and dynamic reassessment. This approach is based on the most recent guidelines, specifically the 2024 ESC Guidelines for the management of atrial fibrillation 1. The initial evaluation should include 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 acute atrial fibrillation include:

• Rate control therapy with beta-blockers, digoxin, or diltiazem/verapamil as initial therapy in the acute setting
• Rhythm control, which should be considered in all suitable AF patients, with explicit discussion of the potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation
• Anticoagulation, with oral anticoagulants recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism
• The choice of anticoagulant, with DOACs preferred over VKAs, except in patients with mechanical heart valves and mitral stenosis

The CHA2DS2-VA score should be used to guide long-term anticoagulation decisions, with anticoagulation recommended for patients with a score of 2 or higher 1. It is also important to manage modifiable bleeding risk factors to improve safety, and to avoid combining anticoagulants and antiplatelet agents unless necessary.

In terms of specific treatment options, beta-blockers, such as metoprolol, are recommended as first-line therapy for rate control, with a dose of 5mg IV every 5 minutes up to 3 doses 1. For rhythm control, electrical cardioversion is recommended in cases of hemodynamic instability, while pharmacological cardioversion may be attempted in stable patients 1.

Overall, the management of acute atrial fibrillation requires a comprehensive approach that takes into account the individual patient's risk factors, symptoms, and medical history, with the goal of reducing symptoms, preventing thromboembolic events, and improving quality of life.

From the FDA Drug Label

Diltiazem Hydrochloride Injection or Diltiazem Hydrochloride for Injection are indicated for the following: Atrial Fibrillation or Atrial Flutter Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter Unless otherwise contraindicated, appropriate vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection The use of diltiazem hydrochloride injection or diltiazem hydrochloride for injection should be undertaken with caution when the patient is compromised hemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium For either indication and particularly when employing continuous intravenous infusion, the setting should include continuous monitoring of the ECG and frequent measurement of blood pressure. A defibrillator and emergency equipment should be readily available Bolus administration of diltiazem hydrochloride injection was effective in reducing heart rate by at least 20% in 95% of patients. Response usually occurs within 3 minutes and maximal heart rate reduction generally occurs in 2 to 7 minutes.

The management of acute atrial fibrillation involves:

• Temporary control of rapid ventricular rate using diltiazem hydrochloride injection
• Vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection, unless contraindicated
• Continuous monitoring of the ECG and frequent measurement of blood pressure
• Caution when using diltiazem hydrochloride injection in patients who are compromised hemodynamically or taking other drugs that decrease peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium
• Emergency equipment should be readily available, including a defibrillator 2

From the Research

Management Strategies

The management of acute atrial fibrillation can be divided into several strategies, including:

• Rate control: This approach focuses on controlling the heart rate to prevent symptoms and complications 3, 4, 5, 6.
• Rhythm control: This approach aims to restore and maintain a normal sinus rhythm, often using antiarrhythmic medications or electrical cardioversion 3, 4, 5, 6.
• Antithrombotic therapy: This approach involves the use of anticoagulant or antiplatelet medications to prevent stroke and other thromboembolic events 3, 4, 5, 6, 7.

Treatment Options

The treatment of acute atrial fibrillation may involve:

• Pharmacological cardioversion: The use of antiarrhythmic medications, such as amiodarone, flecainide, or propafenone, to restore a normal sinus rhythm 3, 4, 5.
• Direct current cardioversion: The use of electrical shocks to restore a normal sinus rhythm, often used in patients with hemodynamic instability 3, 4, 7.
• Rate control medications: The use of medications, such as beta blockers, calcium channel blockers, or digoxin, to control the heart rate 3, 4, 5, 6.
• Anticoagulation: The use of anticoagulant medications, such as warfarin or aspirin, to prevent stroke and other thromboembolic events 3, 4, 5, 6, 7.

Patient Assessment

The management of acute atrial fibrillation requires a thorough assessment of the patient's clinical status, including:

• Hemodynamic stability: Patients with hemodynamic instability may require urgent direct current cardioversion or other interventions 3, 4.
• Underlying heart disease: Patients with underlying heart disease may require additional treatments or considerations 3, 4, 5, 6.
• Risk of thromboembolic events: Patients with a high risk of thromboembolic events may require anticoagulation therapy 3, 4, 5, 6, 7.