What are the guidelines for managing Atrial Fibrillation (AF)?

Guidelines for Management of Atrial Fibrillation

The management of atrial fibrillation should follow the AF-CARE pathway, which includes comorbidity management, anticoagulation for stroke prevention, rate/rhythm control for symptom reduction, and regular evaluation with dynamic reassessment. 1

Initial Assessment and Classification

1. Classification of AF:

   • First diagnosed AF: First presentation regardless of duration
   • Paroxysmal AF: Self-terminating, usually within 48 hours
   • Persistent AF: Episode lasting >7 days or requiring cardioversion
   • Long-standing persistent AF: Continuous AF lasting ≥1 year when rhythm control is pursued
   • Permanent AF: When AF is accepted by patient and physician 2

2. Symptom Assessment:

   • Use EHRA score to evaluate symptom severity 2
   • Document heart rhythm regularity, precipitating factors, symptom severity, frequency and duration of episodes 2

Stroke Risk Assessment and Anticoagulation

1. Risk Stratification:

   • Use CHA₂DS₂-VASc score for all patients 1
   • Men with score ≥2 or women with score ≥3: Strong recommendation for anticoagulation 1
   • Patients with one 'major' risk factor or ≥2 'clinically relevant non-major' risk factors: Oral anticoagulation recommended 2

2. Anticoagulation Options:

   • DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) preferred over VKAs except in mechanical heart valves or mitral stenosis 1
   • For VKAs: Target INR 2.0-3.0 with time in therapeutic range >70% 1
   • Monitor INR weekly during initiation, monthly when stable 2

3. Special Situations:

   • Recent-onset AF (<48h): Can cardiovert with LMWH without significant stroke risk 2
   • AF >48h or unknown duration: Anticoagulate for 3-4 weeks before and after cardioversion 2
   • Alternative: TEE to rule out thrombus before cardioversion 2

Rate Control Strategy

1. Target Heart Rate:

   • Initial approach: Resting heart rate <110 beats/min (lenient control) 1

2. Medication Options:

   • First-line: Beta-blockers, non-dihydropyridine calcium channel blockers (diltiazem, verapamil), digoxin 1
   • Consider combination therapy (digoxin plus beta-blocker or calcium channel antagonist) to control rate at rest and during exercise 2
   • Avoid digoxin as sole agent for paroxysmal AF 2

3. When Pharmacological Therapy Insufficient:

   • Consider non-pharmacological therapy (e.g., ablation) 2

Rhythm Control Strategy

1. Cardioversion Options:

   • Immediate electrical cardioversion for hemodynamically unstable patients 2
   • Pharmacological cardioversion:
     • Without structural heart disease: Flecainide or propafenone 1
     • With severe LV hypertrophy, HFrEF, or CAD: Amiodarone IV 1
     • Avoid sotalol or digoxin for cardioversion 1

2. Long-term Antiarrhythmic Therapy:

   • HFrEF: Amiodarone (monitor for extracardiac toxicity) 1
   • HFmrEF, HFpEF, ischemic heart disease, valvular disease: Dronedarone 1
   • No impaired LV function, severe LV hypertrophy, or CAD: Flecainide or propafenone 1
   • Avoid amiodarone for long-term maintenance when possible due to irreversible side effects 1

3. Catheter Ablation:

   • Recommended for paroxysmal/persistent AF resistant/intolerant to antiarrhythmic drugs 1
   • Consider as first-line for paroxysmal AF 1
   • Strongly recommended for AF with HFrEF and high probability of tachycardia-induced cardiomyopathy 1, 3
   • Maintain uninterrupted anticoagulation during procedure and continue for ≥2 months post-ablation 1

Comorbidity and Risk Factor Management

1. Hypertension: ACE inhibitors or ARBs as first-line therapy 1
2. Heart Failure: Optimize therapy, especially in HFrEF 1
3. Obesity: Target normal weight (BMI 20-25 kg/m²) 1
4. Physical Activity: 150-300 min/week moderate or 75-150 min/week vigorous activity 1
5. Alcohol: Avoid binge drinking and excessive consumption 1
6. Sleep Apnea: Consider evaluation and treatment 1

Follow-up and Monitoring

1. Regular Risk Reassessment:

   • Stroke and bleeding risk are dynamic and increase over time 4
   • Reassess CHA₂DS₂-VASc score regularly as patients age and accumulate comorbidities 4
   • Highest risk of events occurs within months after increases in risk scores 4

2. Monitoring Anticoagulation:

   • Do not discontinue anticoagulation based solely on perceived success of ablation 1
   • For VKAs: Monitor INR at least weekly during initiation, monthly when stable 2

Flow Chart for AF Management

Initial AF Diagnosis
│
├── Assess Hemodynamic Stability
│   ├── Unstable → Immediate Electrical Cardioversion
│   └── Stable → Continue Assessment
│
├── Assess Stroke Risk (CHA₂DS₂-VASc)
│   ├── Men: Score 0, Women: Score 1 → No Anticoagulation
│   ├── Men: Score 1 → Consider Anticoagulation
│   └── Men: Score ≥2, Women: Score ≥3 → Anticoagulation
│       ├── No Mechanical Valve/Mitral Stenosis → DOAC Preferred
│       └── Mechanical Valve/Mitral Stenosis → VKA (INR 2.0-3.0)
│
├── Symptom Management Strategy
│   ├── Rate Control
│   │   ├── Beta-blockers, Non-DHP CCBs, or Digoxin
│   │   └── Target HR <110 bpm at rest
│   │
│   └── Rhythm Control
│       ├── Recent-onset AF (<48h)
│       │   ├── No Structural Heart Disease → Flecainide/Propafenone
│       │   └── With Structural Heart Disease → Amiodarone
│       │
│       ├── AF >48h or Unknown Duration
│       │   ├── Anticoagulate 3-4 weeks before cardioversion
│       │   └── OR TEE to rule out thrombus
│       │
│       └── Long-term Management
│           ├── No Structural Heart Disease → Flecainide/Propafenone
│           ├── HFrEF → Amiodarone
│           ├── HFmrEF/HFpEF/CAD → Dronedarone
│           └── Consider Catheter Ablation if:
│               ├── Drug-resistant/intolerant
│               ├── Paroxysmal AF (first-line option)
│               └── AF with HFrEF
│
└── Risk Factor Management
    ├── Hypertension → ACE-I/ARB
    ├── Heart Failure → Optimize therapy
    ├── Obesity → Target BMI 20-25
    ├── Physical Activity → Regular exercise
    ├── Alcohol → Limit consumption
    └── Sleep Apnea → Evaluate and treat

Regular reassessment of stroke and bleeding risk is essential as these risks increase over time with age and accumulating comorbidities 4.