What is the management of atrial fibrillation?

Management of Atrial Fibrillation

The management of atrial fibrillation requires a three-pronged approach focusing on stroke prevention through anticoagulation, ventricular rate control, and rhythm control strategies based on symptom severity and patient characteristics. 1

Stroke Prevention

Anticoagulation Therapy

• All patients with AF should receive antithrombotic therapy (oral anticoagulation or aspirin) except those with lone AF 1
• Risk stratification determines anticoagulation approach:
  • Age ≥75 years (especially women): Oral anticoagulation with INR 2.0-3.0 1
  • Heart failure, LV ejection fraction ≤0.35, hypertension, or rheumatic heart disease: Oral anticoagulation with INR 2.0-3.0 1
  • Age <60 years with no heart disease (lone AF): Aspirin 325 mg daily or no therapy 1
  • Age <60 years with heart disease but no risk factors: Aspirin 325 mg daily 1

Anticoagulation Monitoring

• INR should be checked weekly during initiation and monthly when stable 1
• For cardioversion, anticoagulate patients with AF >48 hours or unknown duration for at least 3-4 weeks before and after cardioversion (INR 2-3) 1

Rate Control Strategy

First-line Medications

• Beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are first-line therapy for rate control 1, 2
• Target resting heart rate <100 beats per minute 2
• Combination therapy options:
  • Beta-blocker + digoxin
  • Calcium channel blocker + digoxin
  • Consider combination of digoxin and beta-blocker or calcium channel antagonist to control rate at rest and during exercise 1

Special Considerations

• In patients with heart failure or LV dysfunction: Beta-blockers preferred 3
• In patients with COPD/bronchospasm: Non-dihydropyridine calcium channel antagonists preferred; beta-1 selective blockers (e.g., bisoprolol) in small doses may be considered 1
• Digoxin should not be used as monotherapy for rate control in active patients or those with paroxysmal AF 1, 2

Rhythm Control Strategy

Cardioversion

• Immediate electrical cardioversion is recommended for patients with AF and:

  • Hemodynamic instability
  • Ongoing myocardial ischemia
  • Symptomatic hypotension
  • Angina
  • Heart failure not responding to pharmacological measures 1

• For elective cardioversion:

  • Pre-treatment with amiodarone, flecainide, propafenone, ibutilide, or sotalol should be considered to enhance success and prevent recurrence 1
  • Direct current cardioversion (DCC) is preferred with biphasic shocks 1

Antiarrhythmic Drug Selection

• For maintenance of sinus rhythm:
  • No structural heart disease: Dronedarone, flecainide, propafenone, or sotalol 2
  • Abnormal ventricular function (LVEF >35%): Dronedarone, sotalol, or amiodarone 2
  • LVEF <35%: Amiodarone is the only recommended option 2
  • Hypertrophic cardiomyopathy: Amiodarone or disopyramide plus beta-blocker 1

Catheter Ablation

• Consider for patients who remain symptomatic after adequate trials of antiarrhythmic drugs 2
• First-line therapy for symptomatic paroxysmal AF to improve symptoms 4
• Particularly beneficial in patients with AF and heart failure with reduced ejection fraction 4

Special Populations

Wolff-Parkinson-White Syndrome with AF

• Catheter ablation is recommended for patients with evidence of antegrade accessory pathway conduction and AF 1
• Immediate cardioversion required for rapid tachycardias or hemodynamic instability 1
• IV amiodarone may be used in hemodynamically stable patients 1

Hypertrophic Cardiomyopathy with AF

• Restoration of sinus rhythm by cardioversion recommended for recent-onset AF 1
• Oral anticoagulation (INR 2.0-3.0) recommended unless contraindicated 1
• Amiodarone or disopyramide plus beta-blocker for rhythm control 1

Pulmonary Disease with AF

• Correction of hypoxemia and acidosis is initial management 1
• Non-dihydropyridine calcium channel antagonists preferred for rate control 1
• Avoid theophylline, beta-adrenergic agonists, non-selective beta-blockers, sotalol, propafenone, and adenosine 1

Common Pitfalls and Caveats

1. Inadequate anticoagulation: Failing to provide appropriate stroke prevention based on risk factors
2. Overuse of digoxin as monotherapy: Digoxin alone is insufficient for rate control in active patients
3. Inappropriate antiarrhythmic drug selection: Not considering underlying heart disease when choosing rhythm control medications
4. Delayed cardioversion: Not performing immediate cardioversion in hemodynamically unstable patients
5. Inadequate rate monitoring: Not assessing rate control during both rest and activity
6. Ignoring reversible causes: Not identifying and treating underlying conditions (hyperthyroidism, electrolyte abnormalities, etc.)
7. Neglecting symptom assessment: Focusing solely on heart rate without addressing patient symptoms and quality of life

Remember that management should focus on reducing symptoms, improving quality of life, and minimizing morbidity associated with AF 2.