Initial Treatment for Atrial Fibrillation
The initial treatment for atrial fibrillation should include rate control therapy with beta-blockers, diltiazem, verapamil, or digoxin, along with assessment for stroke risk and appropriate anticoagulation therapy. 1
Initial Evaluation and Management
- A comprehensive initial evaluation should include medical history, assessment of symptoms, blood tests, echocardiography, and assessment of risk factors for thromboembolism and bleeding 1
- Management of comorbidities and risk factors (hypertension, heart failure, diabetes, obesity, sleep apnea, physical inactivity, alcohol intake) is critical to prevent AF progression and improve treatment outcomes 1
Rate Control Strategy
- Rate control therapy is recommended as initial therapy in the acute setting, as an adjunct to rhythm control, or as a sole treatment strategy 1
- For patients with AF and LVEF >40%: beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs 1
- For patients with AF and LVEF ≤40%: beta-blockers and/or digoxin are recommended 1
- The goal of rate control is to manage symptoms and prevent tachycardia-induced cardiomyopathy 2
Anticoagulation Therapy
- Assess stroke risk using CHA₂DS₂-VA score to guide anticoagulation decisions 1
- Oral anticoagulants are recommended for patients with CHA₂DS₂-VA score ≥2 and should be considered for those with a score of 1 1
- Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban are preferred over vitamin K antagonists (VKAs) like warfarin 1, 3
- VKAs remain the preferred option for patients with mechanical heart valves and mitral stenosis 1
- Apixaban has demonstrated superiority to warfarin in reducing stroke and systemic embolism with lower rates of major bleeding 3
- Antiplatelet therapy alone is not recommended for stroke prevention in AF 2, 4
Rhythm Control Considerations
- Consider rhythm control in all suitable AF patients after discussing potential benefits and risks 1
- For patients with acute or worsening hemodynamic instability, electrical cardioversion is recommended 1
- For pharmacological cardioversion of recent-onset AF:
- Intravenous flecainide or propafenone is recommended (except in patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease) 1
- Intravenous vernakalant is recommended (except in patients with recent ACS, HFrEF, or severe aortic stenosis) 1
- Intravenous amiodarone is recommended for patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease 1
Important Considerations and Pitfalls
- Ensure therapeutic anticoagulation for at least 3 weeks before scheduled cardioversion if AF duration is >24 hours 1
- Early cardioversion without appropriate anticoagulation or transesophageal echocardiography is not recommended if AF duration is >24 hours 1
- Avoid combining anticoagulants and antiplatelet agents unless the patient has an acute vascular event or needs interim treatment for procedures 1
- Do not use reduced doses of DOACs unless patients meet specific dose-reduction criteria 1
- Continue anticoagulation according to the patient's stroke risk, regardless of whether they are in AF or sinus rhythm 1
- Bleeding risk assessment should not determine whether to start or withdraw anticoagulation 1
Long-term Management Considerations
- Catheter ablation can be considered as a second-line option if antiarrhythmic drugs fail, or as first-line in patients with paroxysmal AF 1
- Periodically reassess therapy and address new modifiable risk factors to slow/reverse AF progression and prevent adverse outcomes 1
- Early rhythm control strategy should be considered within 12 months of diagnosis in selected patients with AF at risk of thromboembolic events 1