What is the treatment for atrial fibrillation?

Treatment of Atrial Fibrillation

The optimal treatment for atrial fibrillation includes rate control with beta-blockers, calcium channel blockers, or digoxin (based on cardiac function), anticoagulation for stroke prevention, and consideration of rhythm control in select patients. 1

Initial Assessment and Treatment Strategy

Rate Control

Rate control is the recommended initial strategy for most patients with atrial fibrillation, particularly in the acute setting 1.

For patients with preserved left ventricular function (LVEF >40%):

• First-line options:
  • Beta-blockers (metoprolol, atenolol)
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
  • Digoxin (particularly effective when combined with other agents) 1

For patients with reduced left ventricular function (LVEF ≤40%):

• First-line options:
  • Beta-blockers
  • Digoxin (alone or in combination) 1
  • Avoid calcium channel blockers due to negative inotropic effects 1

In hemodynamically unstable patients:

• Immediate electrical cardioversion is recommended 1
• IV amiodarone, digoxin, or beta-blockers (esmolol, landiolol) may be considered for acute rate control 1

Anticoagulation for Stroke Prevention

Anticoagulation therapy should be initiated based on stroke risk assessment:

• CHA₂DS₂-VASc score determines need for anticoagulation
• Oral anticoagulants (warfarin with target INR 2-3 or direct oral anticoagulants) are recommended for patients with risk factors 1
• Aspirin may be considered for primary prevention in patients <60 years without heart disease or risk factors (lone AF) 1

Special Clinical Scenarios

Atrial Fibrillation with Heart Failure

• Beta-blockers and/or digoxin are recommended for rate control 1
• For patients with HF who develop AF, a rhythm-control strategy is not superior to rate-control 1
• AV node ablation with pacemaker implantation should be considered in patients unresponsive to medical therapy 1

Postoperative Atrial Fibrillation

• Oral beta-blockers are recommended to prevent postoperative AF 1
• For patients who develop postoperative AF, AV nodal blocking agents are recommended 1
• Prophylactic sotalol or amiodarone may be considered for high-risk patients 1

Atrial Fibrillation with WPW Syndrome

• Immediate electrical cardioversion for hemodynamically unstable patients 1
• IV procainamide or ibutilide for hemodynamically stable patients 1
• Avoid beta-blockers, digoxin, diltiazem, and verapamil in patients with pre-excited AF 1

Atrial Fibrillation with Thyrotoxicosis

• Beta-blockers are first-line therapy 1
• Calcium channel antagonists if beta-blockers are contraindicated 1

Rhythm vs. Rate Control

While rate control is the initial approach for most patients, rhythm control may be considered for:

• Younger patients
• Highly symptomatic patients
• First episode of AF
• Tachycardia-induced cardiomyopathy 1

Recent evidence suggests that diltiazem may be more effective than metoprolol for rapid rate control in the emergency department setting 2 and may reduce NT-proBNP levels and improve symptoms in patients with permanent AF 3.

Potential Pitfalls and Caveats

• Anticoagulation interruption: Interrupting anticoagulation for procedures increases stroke risk; consider bridging with heparin for high-risk patients 1
• Drug interactions: Amiodarone has multiple drug interactions, particularly with oral anticoagulants 1
• Proarrhythmic effects: Class IC antiarrhythmic drugs (flecainide) are contraindicated in patients with structural heart disease or coronary artery disease 4
• Monitoring requirements: Regular monitoring of heart rate, blood pressure, and anticoagulation status is essential

The AFFIRM and RACE trials demonstrated that rate control with anticoagulation is as effective as rhythm control for most patients with atrial fibrillation, with fewer hospitalizations and similar mortality and stroke rates 1.