How to manage atrial fibrillation according to NICE (National Institute for Health and Care Excellence) CKS (Clinical Knowledge Summaries)?

Management of Atrial Fibrillation According to NICE CKS Guidelines

Beta-blockers or non-dihydropyridine calcium channel antagonists should be used as first-line therapy for rate control in most patients with atrial fibrillation, with a target resting heart rate of <100 beats per minute.

Rate Control Strategy

First-line medications:

• Beta-blockers: Metoprolol, bisoprolol, esmolol

  • Dosage: Metoprolol 25-100 mg orally twice daily or 2.5-5 mg IV bolus
  • Particularly effective in patients with hypertension or coronary artery disease
  • Preferred for patients with heart failure 1

• Non-dihydropyridine calcium channel antagonists: Diltiazem, verapamil

  • Dosage: Diltiazem 40-120 mg orally three times daily or 0.25 mg/kg IV over 2 minutes
  • Particularly effective for rate control during exercise
  • Preferred for patients with COPD/pulmonary disease 1
  • Contraindicated in patients with decompensated heart failure 1

Special situations:

• Heart failure patients: Use beta-blockers or digoxin

  • Digoxin dosage: 0.25 mg IV every 2 hours (up to 1.5 mg) or 0.125-0.25 mg orally daily
  • Intravenous digoxin or amiodarone is recommended for acute rate control 1
  • Digoxin should not be used as monotherapy for paroxysmal AF 1

• COPD/pulmonary disease patients:

  • Non-dihydropyridine calcium channel antagonists are preferred 1
  • Beta-1 selective blockers (e.g., bisoprolol) in small doses can be considered as an alternative 1
  • Avoid non-selective beta-blockers, sotalol, propafenone, and adenosine 1

Anticoagulation Strategy

Anticoagulation therapy should be based on stroke risk assessment using the CHA₂DS₂-VASc score:

• High-risk patients (prior stroke/TIA/thromboembolism, rheumatic mitral stenosis, or multiple risk factors):

  • Oral anticoagulation with warfarin (target INR 2.0-3.0) 1, 2
  • Direct oral anticoagulants (DOACs) are a viable alternative

• Moderate-risk patients (age ≥75 years, hypertension, heart failure, diabetes mellitus, or vascular disease):

  • Oral anticoagulation with warfarin or DOACs 1, 2

• Low-risk patients:

  • Aspirin 81-325 mg daily 1

• Before cardioversion:

  • Anticoagulation for at least 3 weeks before and 4 weeks after cardioversion for AF ≥48 hours or unknown duration 2

Rhythm Control Strategy

Consider rhythm control for symptomatic patients or those with difficulty achieving adequate rate control:

1. Electrical cardioversion:

   • First-line for hemodynamically unstable patients
   • Requires prior anticoagulation if AF duration ≥48 hours

2. Pharmacological cardioversion:

   • Ibutilide or amiodarone for hemodynamically stable patients
   • Flecainide or propafenone for patients without structural heart disease

3. Catheter ablation:

   • Consider when pharmacological therapy is insufficient or associated with side effects 1
   • AV node ablation with pacemaker implantation for difficult-to-control AF

Monitoring and Follow-up

• Monitor INR at least weekly during initiation of warfarin therapy and monthly when stable 1
• Assess adequacy of rate control during exercise for patients with symptoms during activity 1
• Evaluate for tachycardia-induced cardiomyopathy in patients with prolonged uncontrolled AF

Common Pitfalls to Avoid

1. Using digitalis as the sole agent for rate control in paroxysmal AF 1
2. Administering non-dihydropyridine calcium channel antagonists to patients with decompensated heart failure 1
3. Using intravenous digitalis or calcium channel blockers in patients with preexcitation syndrome 1
4. Attempting catheter ablation without a prior trial of medication for rate control 1
5. Using theophylline or beta-adrenergic agonists in patients with bronchospastic lung disease who develop AF 1

By following these guidelines, clinicians can effectively manage atrial fibrillation while reducing the risk of complications and improving patient outcomes.