What are the management options for Atrial Fibrillation (AF)?

AF-CARE: Comprehensive Management of Atrial Fibrillation

The management of atrial fibrillation should follow the AF-CARE pathway, which includes Comorbidity and risk factor management, Avoiding stroke through anticoagulation, Reducing symptoms with rate and rhythm control, and Evaluation with dynamic reassessment. 1

C - Comorbidity and Risk Factor Management

Addressing underlying conditions is critical for preventing AF recurrence and progression:

• Hypertension: Maintain optimal blood pressure with ACE inhibitors or ARBs as first-line therapy 1
• Heart failure: Optimize HF therapy, especially in HFrEF where ACE inhibitors/ARBs reduce AF incidence by 44% and beta-blockers by 33% 1
• Obesity: Target normal weight (BMI 20-25 kg/m²) 1
• Physical activity: Maintain active lifestyle (150-300 min/week moderate or 75-150 min/week vigorous activity) 1
• Alcohol: Avoid binge drinking and excessive alcohol consumption 1
• Sleep apnea: Consider evaluation and treatment, though evidence for CPAP preventing AF is limited 1

A - Avoid Stroke and Thromboembolism

Anticoagulation decisions should be based on stroke risk assessment:

• Risk stratification: Use CHA₂DS₂-VASc score 1

  • Score ≥2 in men or ≥3 in women: Anticoagulation strongly recommended
  • Score 1 in men or 2 in women: Anticoagulation should be considered
  • Score 0 in men or 1 in women: No antithrombotic therapy needed

• Anticoagulant selection:

  • DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) preferred over VKAs except in patients with mechanical heart valves or mitral stenosis 1
  • For VKAs, maintain INR 2.0-3.0 with time in therapeutic range >70% 1

• Periablation anticoagulation:

  • Initiate oral anticoagulation ≥3 weeks before catheter ablation 1
  • Maintain uninterrupted anticoagulation during procedure 1
  • Continue for ≥2 months post-ablation regardless of outcome or CHA₂DS₂-VASc score 1
  • Long-term anticoagulation based on CHA₂DS₂-VASc score, not perceived ablation success 1

R - Reduce Symptoms (Rate and Rhythm Control)

Rate Control Strategy

• Initial approach: Target resting heart rate <110 beats/min (lenient control) 2
• First-line agents:
  • Beta-blockers (achieve rate control in 70% of patients) 2
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 2
  • Digoxin for patients with heart failure or LV dysfunction (not as sole agent) 2

Rhythm Control Strategy

• Indications: Patients who remain symptomatic despite adequate rate control, young symptomatic patients, AF with heart failure, or paroxysmal AF with minimal heart disease 2

• Pharmacological cardioversion:

  • Flecainide or propafenone for recent-onset AF without structural heart disease 1
  • Vernakalant IV for recent-onset AF (avoid in recent ACS, HFrEF, severe aortic stenosis) 1
  • Amiodarone IV for patients with severe LV hypertrophy, HFrEF, or coronary artery disease 1

• Long-term antiarrhythmic therapy:

  • Amiodarone for AF with HFrEF (monitor for extracardiac toxicity) 1
  • Dronedarone for AF with HFmrEF, HFpEF, ischemic heart disease, or valvular disease 1
  • Flecainide or propafenone for patients without impaired LV function, severe LV hypertrophy, or coronary artery disease 1
  • Avoid antiarrhythmic drugs in patients with advanced conduction disturbances unless pacing is provided 1

• Catheter ablation:

  • Recommended for paroxysmal or persistent AF resistant/intolerant to antiarrhythmic drugs 1
  • First-line option for paroxysmal AF within shared decision-making strategy 1
  • Recommended for AF with HFrEF and high probability of tachycardia-induced cardiomyopathy 1

• Surgical options:

  • Concomitant surgical ablation recommended during mitral valve surgery in patients with AF 1

E - Evaluation and Dynamic Reassessment

Regular monitoring is essential:

• Initial evaluation: Medical history, symptom assessment, blood tests, echocardiography 1
• ECG monitoring: Within 2-4 weeks after intervention to assess rhythm maintenance 2
• Medication monitoring: Regular assessment for side effects of antiarrhythmic drugs 2
• Anticoagulation reassessment: Periodic evaluation of stroke and bleeding risks 1

Shared Decision-Making

Involve patients in treatment decisions, particularly when considering catheter ablation, taking into account procedural risks, likely benefits, and risk factors for AF recurrence 1.

Pitfalls and Caveats

• Do not discontinue anticoagulation based solely on perceived success of ablation procedure 1
• Avoid antiarrhythmic drugs in patients with conduction disturbances without pacing 1
• Do not use sotalol or digoxin for pharmacological cardioversion 2
• Avoid amiodarone for long-term maintenance when possible due to irreversible side effects 2
• Do not use aspirin alone for stroke prevention in AF as it has poor efficacy 3