What is the initial treatment for atrial fibrillation?

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 appropriate anticoagulation therapy based on stroke risk assessment, followed by consideration of rhythm control strategies in selected 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% to control heart rate and reduce symptoms 1, 2
• For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended for rate control 2
• Rate control therapy is recommended as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy 1

Anticoagulation Therapy

• Stroke risk assessment using the CHA₂DS₂-VA score should be performed, with anticoagulation therapy considered for scores ≥1 and recommended for scores ≥2 2
• Direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban are preferred over vitamin K antagonists (VKAs) like warfarin for stroke prevention 2, 3, 4
• Apixaban has demonstrated superiority to warfarin for reducing the risk of stroke and systemic embolism, with significantly fewer major bleeding events 3
• Patients with atrial fibrillation should take rivaroxaban once daily with the evening meal 4
• Anticoagulation should be continued according to the patient's stroke risk even after successful rhythm control 2

Rhythm Control Strategy

• Cardioversion (electrical or pharmacological) should be considered in symptomatic patients with persistent AF as part of a rhythm control approach 1
• Implementation of a rhythm control strategy should be considered within 12 months of diagnosis in selected patients with AF at risk of thromboembolic events 1
• For patients with recurrent paroxysmal AF and no or minimal heart disease, flecainide, propafenone, or sotalol is recommended as initial antiarrhythmic therapy 1
• For patients with heart failure, safety data support the selection of amiodarone or dofetilide to maintain sinus rhythm 1
• Catheter ablation should be considered as a second-line option if antiarrhythmic drugs fail to control atrial fibrillation, or as a first-line option in patients with paroxysmal atrial fibrillation 2, 5

Management of Comorbidities

• Management of comorbidities and risk factors, such as hypertension, heart failure, diabetes, obesity, and obstructive sleep apnea, is critical to prevent atrial fibrillation progression and improve treatment outcomes 2
• Lifestyle and risk factor modification, including weight loss and exercise, are recommended to prevent AF onset, recurrence, and complications 5

Common Pitfalls and Caveats

• Early cardioversion is not recommended without appropriate anticoagulation or transesophageal echocardiography if AF duration is longer than 24 hours 1
• Antiarrhythmic drug therapy is not recommended in patients with advanced conduction disturbances unless antibradycardia pacing is provided 1, 2
• Adding antiplatelet treatment to oral anticoagulation is not recommended in AF patients for the goal of preventing ischemic stroke or thromboembolism 1
• Bleeding risk scores should not be used to decide on starting or withdrawing anticoagulation 2
• Aspirin is associated with poorer efficacy compared to anticoagulation and is not recommended for stroke prevention 5