What is the management approach for atrial fibrillation?

Atrial Fibrillation Management Dot Phrase

The management of atrial fibrillation should follow a structured approach focusing on rate control with beta-blockers or non-dihydropyridine calcium channel blockers as first-line therapy, anticoagulation based on CHA₂DS₂-VASc score, and consideration of rhythm control in selected patients. 1, 2

Initial Assessment

• Assess hemodynamic stability
  • If unstable: Immediate electrical cardioversion (Class I) 2
  • If stable: Proceed with rate control strategy 2
• Evaluate for reversible causes (thyrotoxicosis, electrolyte abnormalities, infection)
• Obtain 12-lead ECG to confirm diagnosis
• Check cardiac enzymes in patients with concerning symptoms or risk factors

Rate Control Strategy

• First-line agents (Class I recommendation) 1, 2:
  • Beta-blockers (metoprolol, esmolol, propranolol)
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
  • Target heart rate: 60-100 bpm at rest, 90-115 bpm with moderate exercise
• Special situations:
  • Heart failure with reduced EF: Beta-blockers or digoxin 1, 2
  • Heart failure with preserved EF: Beta-blockers, diltiazem, verapamil, or digoxin 3
  • AVOID calcium channel blockers and beta-blockers in WPW syndrome (Class III) 1, 2

Anticoagulation Strategy

• Initiate based on CHA₂DS₂-VASc score:
  • Score ≥2 in men or ≥3 in women: Anticoagulation recommended 2
  • Score 1 in men or 2 in women: Consider anticoagulation
  • Score 0 in men or 1 in women: No anticoagulation needed
• Preferred agents:
  • Direct oral anticoagulants (DOACs) preferred over warfarin in eligible patients 1, 2
  • Warfarin (target INR 2.0-3.0) for patients with mechanical valves or severe mitral stenosis
• Assess bleeding risk using HAS-BLED score and address modifiable risk factors

Rhythm Control Strategy

• Consider in:
  • Symptomatic patients despite adequate rate control
  • Younger patients
  • First episode of AF
  • Difficulty achieving adequate rate control
• Options:
  • Pharmacological cardioversion: Ibutilide, amiodarone, or sotalol 1, 2
  • Electrical cardioversion: Particularly effective for recent-onset AF 1, 2
  • Catheter ablation: Consider in symptomatic patients, particularly with WPW syndrome 1, 2
• Rhythm control should be implemented within 12 months of diagnosis in selected patients to reduce cardiovascular death or hospitalization risk 1

Long-term Management

• Regular follow-up to assess:
  • Rate control adequacy
  • Symptoms
  • Medication side effects
  • Stroke risk reassessment
• Lifestyle modifications:
  • Regular moderate physical activity (150-300 min/week)
  • Weight loss (target ≥10% if overweight/obese)
  • Limit alcohol to ≤3 standard drinks per week
  • Blood pressure control
  • Smoking cessation

Monitoring

• ECG at each follow-up visit
• Echocardiogram at baseline and every 1-2 years
• Laboratory monitoring:
  • Complete blood count
  • Renal function
  • Liver function
  • Thyroid function

Complications to Monitor

• Stroke or systemic embolism
• Heart failure exacerbation
• Tachycardia-induced cardiomyopathy
• Bleeding on anticoagulation therapy