What is the treatment for Atrial Fibrillation (AF)?

From the Guidelines

The treatment of atrial fibrillation (AF) should prioritize rate control using beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs to control heart rate and reduce symptoms, as recommended by the 2024 ESC guidelines 1. The primary goals of AF treatment include rate control, rhythm control, and stroke prevention.

• Rate control is essential to reduce symptoms and improve quality of life, with a target heart rate of less than 110 beats per minute at rest.
• Beta-blockers, such as metoprolol, and calcium channel blockers, like diltiazem, are effective options for rate control.
• In patients with severely symptomatic permanent AF and a history of heart failure hospitalization, atrioventricular node ablation combined with cardiac resynchronization therapy may be considered to reduce symptoms and improve outcomes 1. The 2024 ESC guidelines provide the most recent and highest-quality evidence for AF management, superseding previous guidelines like the 2016 ESC guidelines 1. Key considerations in AF treatment include:
• Individualizing treatment based on AF pattern, symptom severity, comorbidities, and patient preferences.
• Using anticoagulation therapy to prevent stroke in patients with risk factors, such as those with a CHA₂DS₂-VASc score ≥2 in men or ≥3 in women.
• Lifestyle modifications, including weight loss, exercise, blood pressure control, and reducing alcohol consumption, as important adjuncts to medical therapy.

From the FDA Drug Label

In ARISTOTLE, patients were randomized to apixaban 5 mg orally twice daily (or 2. 5 mg twice daily in subjects with at least 2 of the following characteristics: age greater than or equal to 80 years, body weight less than or equal to 60 kg, or serum creatinine greater than or equal to 1.5 mg/dL) or to warfarin (targeted to an INR range of 2.0 to 3. 0) The primary objective of ARISTOTLE was to determine whether apixaban 5 mg twice daily (or 2. 5 mg twice daily) was effective (noninferior to warfarin) in reducing the risk of stroke (ischemic or hemorrhagic) and systemic embolism.

The treatment for Atrial Fibrillation (AF) is apixaban 5 mg orally twice daily (or 2.5 mg twice daily in certain patients) or warfarin (targeted to an INR range of 2.0 to 3.0), as shown to be effective in reducing the risk of stroke and systemic embolism in the ARISTOTLE study 2.

• Apixaban was superior to warfarin for the primary endpoint of reducing the risk of stroke and systemic embolism.
• Apixaban also showed significantly fewer major bleeds than warfarin. Alternatively, rivaroxaban was demonstrated to be non-inferior to warfarin for the primary composite endpoint of time to first occurrence of stroke (any type) or non-CNS systemic embolism in the ROCKET AF study 3.

From the Research

Treatment Options for Atrial Fibrillation (AF)

The treatment of AF involves two main tenets: prevention of stroke and systemic embolism, and symptom control with either a rate or a rhythm control strategy 4.

Rate Control Strategy

• Rate control is the preferred management option in most patients, aiming to modulate ventricle rate, alleviate adverse associated symptoms, and improve the quality of life 5, 6.
• The current recommendation for strict rate control is a resting heart rate of less than 80 beats per minute, although more lenient rate control of less than 110 beats per minute while at rest was not inferior to strict rate control in preventing cardiac death, heart failure, stroke, and life-threatening arrhythmias 6.
• Beta-blockers and non-dihydropyridine calcium channel blockers are commonly used in rate control due to their safe nature 4, 5.
• Digoxin may be useful in combination with a beta-blocker to obtain satisfactory rate control, especially in the presence of hypotension or an absolute contraindication to beta-blocker treatment 7.

Rhythm Control Strategy

• Rhythm control is an option for patients in whom rate control cannot be achieved or who have persistent symptoms despite rate control 6.
• A rhythm control strategy with antiarrhythmic medications, with or without catheter ablation, may lead to a reduction in major adverse cardiovascular events, particularly in patients newly diagnosed with AF 4.
• Combination therapy with flecainide and metoprolol has been shown to reduce AF clinical recurrences and improve tolerability at 1-year follow-up in persistent symptomatic AF 8.

Additional Considerations

• Anticoagulation therapy is needed with both rate control and rhythm control to prevent stroke, with warfarin being superior to aspirin and clopidogrel in preventing stroke despite its narrow therapeutic range and increased risk of bleeding 6.
• Surgical options, such as disruption of abnormal conduction pathways in the atria and obliteration of the left atrial appendage, and catheter ablation may be considered in certain patients 6.