What is the treatment approach for atrial fibrillation (AF)?

Treatment Approach for Atrial Fibrillation

The treatment of atrial fibrillation requires a dual approach focusing on stroke prevention through anticoagulation and symptom management through either rate or rhythm control strategies, with direct oral anticoagulants (DOACs) being the preferred anticoagulant option for eligible patients. 1, 2

Initial Assessment and Risk Stratification

• Comprehensive evaluation should include assessment of symptoms, risk factors for thromboembolism, and identification of underlying conditions that may contribute to AF 2
• Stroke risk should be assessed using the CHA₂DS₂-VA score, with anticoagulation therapy considered for scores ≥1 and recommended for scores ≥2 2
• Management of comorbidities such as hypertension, heart failure, diabetes, obesity, and obstructive sleep apnea is critical to prevent AF progression 2

Stroke Prevention with Anticoagulation

• DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) are recommended in preference to vitamin K antagonists (VKAs) like warfarin in eligible patients 1, 2
• Anticoagulation should be continued according to the patient's stroke risk even after successful rhythm control 2
• For patients undergoing cardioversion, anticoagulation is required for at least 3-4 weeks before and after the procedure if AF duration exceeds 48 hours or is unknown 1
• Uninterrupted oral anticoagulation is recommended during catheter ablation procedures to prevent perioperative stroke 1

Rate Control Strategy

• Rate control is recommended as initial therapy in the acute setting, as an adjunct to rhythm control, or as a sole treatment strategy 1
• First-line medications for rate control in patients with LVEF >40% include:
  • Beta-blockers (except sotalol) 1
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 1
  • Digoxin (particularly useful in heart failure patients) 1
• For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended 2
• AV nodal ablation with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF who have had at least one heart failure hospitalization 1

Rhythm Control Strategy

• Rhythm control should be considered for symptomatic patients or within 12 months of diagnosis in selected patients at risk of thromboembolic events 1
• Immediate electrical cardioversion is recommended for patients with hemodynamic instability 1
• For pharmacological cardioversion or maintenance of sinus rhythm, antiarrhythmic drug selection should be based on cardiac status:
  • For patients with no/minimal heart disease: flecainide, propafenone, or sotalol 1
  • For patients with heart failure: amiodarone or dofetilide 1
  • For patients with coronary artery disease: sotalol (if no heart failure) or amiodarone/dofetilide as secondary agents 1

Catheter Ablation

• Catheter ablation should be considered in patients with symptomatic AF refractory to antiarrhythmic drugs 2
• Repeat ablation should be considered in patients with AF recurrence after initial catheter ablation if symptoms improved after the initial procedure 1
• Surgical or endoscopic left atrial appendage closure may be considered as an adjunct to anticoagulation in patients undergoing AF ablation 1

Common Pitfalls and Caveats

• Do not administer intravenous amiodarone, adenosine, digoxin, or non-dihydropyridine calcium channel blockers in patients with Wolff-Parkinson-White syndrome and pre-excited AF as these can accelerate ventricular rate 1
• Antiarrhythmic drugs should not be used in patients with advanced conduction disturbances unless antibradycardia pacing is provided 1
• Reduced doses of DOACs should only be used if patients meet specific dose-reduction criteria 2
• Bleeding risk scores should not be used to decide whether to start or withdraw anticoagulation 2
• Early cardioversion should not be performed without appropriate anticoagulation or transesophageal echocardiography if AF duration is longer than 24 hours 1