Guidelines for Managing Atrial Fibrillation (AFib)
The management of atrial fibrillation requires a structured approach following the AF-CARE pathway: Comorbidity management, Anticoagulation for stroke prevention, Rate/Rhythm control, and regular Evaluation. 1
Diagnosis and Initial Assessment
- Confirm AFib with ECG documentation
- Actively screen with ECG monitoring in high-risk patients, especially elderly and stroke survivors 1
- Assess:
- Symptoms and their impact on quality of life
- Risk factors for thromboembolism using CHA₂DS₂-VASc score
- Bleeding risk factors
- Cardiac structure and function via echocardiography
Stroke Prevention
Risk Stratification
- Use CHA₂DS₂-VASc score to assess stroke risk 1:
- Score ≥2 in males or ≥3 in females: anticoagulation strongly recommended
- Score 1 in males or 2 in females: anticoagulation should be considered
- Score 0 in males or 1 in females: no antithrombotic therapy needed
Anticoagulation Recommendations
- Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists except in patients with mechanical heart valves or mitral stenosis 1
- DOACs include apixaban, dabigatran, edoxaban, and rivaroxaban 2
- For vitamin K antagonists (e.g., warfarin), maintain INR 2.0-3.0 with >70% time in therapeutic range 1
- Higher intensity anticoagulation (INR 2.5-3.5) for patients with prosthetic heart valves, prior thromboembolism, or persistent atrial thrombus 1
- Monitor INR weekly during initiation and monthly when stable 1
- Avoid combining anticoagulants with antiplatelet agents unless specifically indicated 1
Bleeding Risk Management
- Identify and address modifiable bleeding risk factors:
- Control hypertension
- Minimize duration of concurrent antiplatelet/NSAID therapy
- Moderate alcohol intake
- Treat anemia 1
Rate Control Strategy
Acute Setting
- Intravenous beta-blockers or calcium channel antagonists (verapamil, diltiazem) to slow ventricular response 1
- Use caution with calcium channel blockers in patients with hypotension or heart failure 1
Long-term Rate Control
- Target heart rate <110 beats/min at rest initially (lenient control) 1
- First-line agents:
- Beta-blockers (any ejection fraction)
- Non-dihydropyridine calcium channel blockers (diltiazem/verapamil) if LVEF >40%
- Digoxin (any ejection fraction) 1
- Consider combination therapy (digoxin plus beta-blocker or calcium channel antagonist) when single agent insufficient 1
- Avoid digoxin as sole agent for rate control in paroxysmal AFib 1
Rhythm Control Strategy
Indications
- Consider in all suitable AFib patients, primarily to reduce symptoms and improve quality of life 1
- May reduce morbidity and mortality in selected patient groups 1
Cardioversion
- Immediate electrical cardioversion for hemodynamically unstable patients 1
- For stable patients with AFib >48 hours or unknown duration:
- Anticoagulate for at least 3-4 weeks before cardioversion
- Continue anticoagulation for at least 4 weeks after 1
- Alternative: TEE to exclude thrombus before cardioversion 1
Antiarrhythmic Medications
- Options include: dronedarone, flecainide, propafenone, sotalol, or amiodarone 1
- Selection should be guided by safety profile and patient characteristics 1
Catheter Ablation
- Consider as first-line option for paroxysmal AFib 1
- Second-line option if antiarrhythmic drugs fail to control AFib 1
- Recommended for patients with AFib and heart failure with reduced ejection fraction to improve outcomes 2
Special Considerations
- Continue anticoagulation according to stroke risk regardless of rhythm control success 1
- Perioperative AFib: Use beta-blockers for prevention of post-cardiac surgery AFib 1
- For patients with AFib and accessory pathway, avoid digoxin and consider immediate cardioversion for rapid tachycardias 1