Initial Management of Atrial Fibrillation
The initial management of atrial fibrillation should focus on rate control with beta-blockers, diltiazem, verapamil, or digoxin, followed by assessment for anticoagulation based on stroke risk factors, and consideration of rhythm control strategies for symptomatic patients. 1, 2
Rate Control Strategy
- Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs for rate control in patients with atrial fibrillation and left ventricular ejection fraction (LVEF) >40% 1, 2
- For patients with LVEF ≤40%, beta-blockers and/or digoxin should be used for rate control 2
- A combination of digoxin and a beta-blocker or calcium channel antagonist should be considered to control heart rate at rest and during exercise, with dose individualization to avoid bradycardia 1
- Digoxin as the sole agent is not recommended for controlling rapid ventricular response in patients with paroxysmal AF 1
Anticoagulation Therapy
- Antithrombotic therapy (oral anticoagulation or aspirin) should be administered to all patients with AF, except those with lone AF (patients <60 years with no heart disease), to prevent thromboembolism 1
- Stroke risk should be assessed using validated tools, with anticoagulation therapy recommended for patients with risk factors 2
- For patients at high risk of stroke, chronic oral anticoagulant therapy with a target INR of 2-3 is recommended 1
- Direct oral anticoagulants (DOACs) such as apixaban are preferred over vitamin K antagonists (VKAs) like warfarin for eligible patients 1, 3
- Apixaban has demonstrated superiority to warfarin in reducing the risk of stroke and systemic embolism with fewer major bleeding events 3
Rhythm Control Considerations
- Immediate electrical cardioversion should be performed in patients with AF and hemodynamic instability (acute myocardial infarction, symptomatic hypotension, angina, or cardiac failure) 1
- For hemodynamically stable patients, a rhythm control strategy should be considered within 12 months of diagnosis in selected patients to reduce the risk of cardiovascular death or hospitalization 1
- A "wait-and-see" approach for spontaneous conversion to sinus rhythm within 48 hours of AF onset should be considered in patients without hemodynamic compromise 1
- Anticoagulation therapy should be administered regardless of the method used to restore sinus rhythm (electrical or pharmacological) 1
Special Considerations
- For patients with AF lasting more than 48 hours or of unknown duration, anticoagulation for at least 3-4 weeks before and after cardioversion is necessary (INR 2-3) 1
- In patients with AF involving conduction over an accessory pathway, immediate cardioversion is required when very rapid tachycardias or hemodynamic instability occurs 1
- Catheter ablation without prior medical therapy to control AF is not recommended 1
- Management of comorbidities and risk factors (hypertension, heart failure, diabetes, obesity, sleep apnea) is critical to prevent AF progression 2, 4
Common Pitfalls to Avoid
- Administering digitalis as the sole agent to control rapid ventricular response in paroxysmal AF 1
- Early cardioversion without appropriate anticoagulation or transesophageal echocardiography if AF duration is longer than 24 hours 1
- Using bleeding risk scores to decide on starting or withdrawing anticoagulation 2
- Discontinuing anticoagulation after successful rhythm control in patients with stroke risk factors 2, 4
- Using antiarrhythmic drugs in patients with advanced conduction disturbances unless antibradycardia pacing is provided 1, 2