What is the initial management of non-valvular atrial fibrillation (AF)?

Initial Management of Non-Valvular Atrial Fibrillation

The initial management of non-valvular atrial fibrillation requires anticoagulation based on stroke risk assessment using the CHA₂DS₂-VASc score, with direct oral anticoagulants (DOACs) preferred over warfarin in eligible patients. 1, 2

Stroke Risk Assessment

1. Calculate CHA₂DS₂-VASc score to determine stroke risk:

   • Congestive heart failure (1 point)
   • Hypertension (1 point)
   • Age ≥75 years (2 points)
   • Diabetes mellitus (1 point)
   • Prior Stroke/TIA/thromboembolism (2 points)
   • Vascular disease (1 point)
   • Age 65-74 years (1 point)
   • Sex category (female) (1 point)

2. Anticoagulation recommendations based on score:

   • Score ≥2 in men or ≥3 in women: Oral anticoagulation recommended 1
   • Score of 1 in men or 2 in women: Oral anticoagulation may be considered 1
   • Score of 0: Anticoagulation can be omitted 1

Anticoagulation Options

First-line options (for eligible patients):

• Direct Oral Anticoagulants (DOACs): Preferred over warfarin in eligible patients 1, 2, 3
  • Dabigatran
  • Rivaroxaban
  • Apixaban
  • Edoxaban

Alternative option:

• Warfarin: Target INR 2.0-3.0 1, 4
  • Required for patients with mechanical heart valves or severe mitral stenosis 1, 2
  • INR monitoring: Weekly during initiation, monthly when stable 1, 4
  • Consider for patients with end-stage chronic kidney disease (CrCl <15 mL/min) or on hemodialysis 1

Special considerations:

• DOACs are not recommended in patients with mechanical heart valves 1
• DOACs are not recommended in patients with end-stage CKD or on dialysis 1
• For patients with moderate-to-severe CKD, reduced doses of DOACs may be considered 1

Rate Control Strategy

Implement rate control with one of the following medications:

• First-line agents 2:

  • Beta-blockers (metoprolol, esmolol, propranolol)
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)

• Alternative agents:

  • Digoxin (effective at rest but less during activity) 2
  • Combination therapy (beta-blocker + digoxin) for both resting and exercise rate control 2

• Target heart rate: 60-100 bpm at rest, 90-115 bpm with moderate exercise 2

Rhythm Control Considerations

Consider rhythm control strategy for:

• Symptomatic patients despite adequate rate control
• Younger patients
• First episode of AF
• Difficulty achieving adequate rate control 2

Options include:

• Pharmacological cardioversion
• Electrical cardioversion (indicated for hemodynamically unstable patients)
• Catheter ablation 2, 5

Follow-up and Monitoring

• Regular assessment of rate control adequacy, symptoms, and medication side effects 2
• ECG at each follow-up visit 2
• Echocardiogram at baseline and every 1-2 years 2
• Laboratory monitoring: complete blood count, renal function, liver function, and thyroid function 2
• Regular reassessment of stroke and bleeding risks 1, 2

Important Caveats

• Bleeding risk assessment: Use HAS-BLED score to identify and address modifiable bleeding risk factors 2
• Avoid nondihydropyridine calcium channel blockers in decompensated heart failure 2
• Avoid beta-blockers, digoxin, diltiazem, and verapamil in patients with Wolff-Parkinson-White syndrome 2
• DOACs are contraindicated in patients with mechanical heart valves 1
• Aspirin alone is not recommended for stroke prevention in most patients with AF due to inferior efficacy compared to anticoagulation 5

Lifestyle Modifications

• Regular moderate physical activity (150-300 min/week) 2
• Weight loss (target ≥10% if overweight/obese) 2
• Limit alcohol to ≤3 standard drinks per week 2
• Blood pressure control 2
• Smoking cessation 2