What is the treatment for atrial fibrillation (AFib)?

Treatment for Atrial Fibrillation

The management of atrial fibrillation requires a comprehensive approach including anticoagulation, rate control, and possibly rhythm control strategies, with beta-blockers being the first-line option for rate control and direct oral anticoagulants (DOACs) preferred for stroke prevention in eligible patients. 1

Anticoagulation Therapy

• Stroke risk assessment is essential:

  • CHA₂DS₂-VASc score of 0: No anticoagulation needed
  • CHA₂DS₂-VASc score of 1: Consider anticoagulation
  • CHA₂DS₂-VASc score ≥2: Anticoagulation recommended 1

• Anticoagulation options:

  • DOACs (apixaban, rivaroxaban, edoxaban) are preferred over vitamin K antagonists in eligible patients 1, 2
  • Warfarin with target INR 2.0-3.0 is recommended when DOACs are contraindicated 3
  • Continue anticoagulation even after successful rhythm control unless patient is at low stroke risk 1

• Contraindications to anticoagulation:

  • Thrombocytopenia
  • Recent trauma or surgery
  • Alcoholism 1

Rate Control Strategy

• First-line medications:

  • Beta-blockers (e.g., metoprolol) are the preferred initial agents, especially in patients with elevated catecholamine states 4, 1, 5
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are alternatives in patients with preserved left ventricular function 1
  • Diltiazem 360 mg/day has been shown to be more effective than verapamil, metoprolol, or carvedilol for heart rate reduction 6

• Dosing recommendations:

  • Metoprolol: 2.5-5.0 mg IV bolus (up to 3 doses) or 25-100 mg BID orally
  • Diltiazem: 15-25 mg IV bolus or 60-120 mg TID orally (120-360 mg daily modified release)
  • Verapamil: 2.5-10 mg IV bolus or 40-120 mg TID orally (120-480 mg daily modified release) 1

• Target heart rate:

  • 60-100 beats per minute at rest
  • 90-115 beats per minute during moderate exercise 1

• Special considerations:

  • For patients with heart failure and reduced ejection fraction: Beta-blockers or digoxin 4
  • For patients with chronic obstructive pulmonary disease: Non-dihydropyridine calcium channel antagonists 4
  • Avoid beta-blockers, sotalol, propafenone, and adenosine in patients with obstructive lung disease 4

Rhythm Control Strategy

• Indications for rhythm control:

  • Symptomatic patients despite adequate rate control
  • First episode in younger patients
  • AF secondary to corrected precipitant
  • Heart failure patients 1, 2

• Options for rhythm control:

  • Direct current cardioversion (DCC) - first choice in hemodynamically unstable patients 1
  • Pharmacological cardioversion with antiarrhythmic drugs
  • Catheter ablation - recommended as first-line therapy for symptomatic paroxysmal AF 2

• Special considerations for antiarrhythmic drugs:

  • Sotalol requires QT interval monitoring (baseline QT must be ≤450 msec)
  • Dosing based on creatinine clearance: BID if >60 mL/min, QD if 40-60 mL/min, contraindicated if <40 mL/min 7
  • In patients with WPW syndrome and pre-excited AF, avoid amiodarone, adenosine, digoxin, and non-dihydropyridine calcium channel antagonists 4

Acute Management of AF with Rapid Ventricular Response

1. Hemodynamically unstable patients:

   • Immediate direct current cardioversion 4

2. Hemodynamically stable patients:

   • Beta-blockers or calcium channel blockers for rate control 8
   • Consider antiarrhythmic drugs for pharmacological cardioversion in selected patients

3. Special situations:

   • WPW syndrome with pre-excited AF: Procainamide or ibutilide, followed by catheter ablation 4
   • Pulmonary disease: Correct hypoxemia and acidosis first, then consider calcium channel antagonists 4

Lifestyle Modifications

• Blood pressure control (target <140/90 mmHg)
• Weight management (target BMI 20-25 kg/m²)
• Regular physical activity (150-300 min/week moderate intensity)
• Alcohol reduction (≤3 standard drinks per week) 1

Follow-up

• Schedule follow-up within 10 days after initial management
• Monitor for heart rate control, rhythm status, anticoagulation efficacy/safety
• Subsequent follow-up at least every 3-6 months 1