What is the management of atrial fibrillation?

Management of Atrial Fibrillation

Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation, as rhythm control has not been shown to be superior in reducing morbidity and mortality. 1

Stroke Prevention

• Oral anticoagulation is recommended for all atrial fibrillation patients with stroke risk factors to prevent thromboembolism 2
• Direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban are preferred over vitamin K antagonists in eligible patients due to lower risk of intracranial hemorrhage 2, 3, 4
• For patients on warfarin, maintain INR between 2.0-3.0 with weekly monitoring during initiation and monthly when stable 2
• Patients with AF lasting >48 hours or of unknown duration require at least 3-4 weeks of anticoagulation before and after cardioversion 5, 2
• Transesophageal echocardiography with short-term anticoagulation followed by early cardioversion is an appropriate alternative to delayed cardioversion with pre- and post-anticoagulation 1

Rate Control Strategy

• Beta-blockers, diltiazem, verapamil are first-line medications for rate control in patients with preserved ejection fraction (LVEF >40%) 2, 6
• Beta-blockers and/or digoxin are recommended for patients with reduced ejection fraction (LVEF ≤40%) 2
• Specific drugs recommended for their demonstrated efficacy in rate control during exercise and rest include atenolol, metoprolol, diltiazem, and verapamil 1
• Digoxin is only effective for rate control at rest and should only be used as a second-line agent 1, 2
• A combination of digoxin with a beta-blocker or calcium channel antagonist may be more effective for controlling heart rate both at rest and during exercise 2, 7
• For patients with obstructive pulmonary disease, non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) are recommended for rate control 1
• Beta-1 selective blockers in small doses may be considered as an alternative in patients with obstructive pulmonary disease 1

Rhythm Control Considerations

• Rhythm control is appropriate when based on special considerations such as patient symptoms, exercise tolerance, and patient preference 1
• For acute cardioversion to achieve sinus rhythm, both direct-current cardioversion and pharmacological conversion are appropriate options 1
• Electrical cardioversion is recommended for patients with AF causing hemodynamic instability 2
• For patients converted to sinus rhythm, most should not be placed on rhythm maintenance therapy since the risks outweigh the benefits 1
• In selected patients whose quality of life is compromised by AF, recommended agents for rhythm maintenance include amiodarone, disopyramide, propafenone, and sotalol 1
• Catheter ablation should be considered when antiarrhythmic medications fail to control symptoms 2, 8
• Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with symptomatic paroxysmal AF or heart failure with reduced ejection fraction 9

Special Considerations

Hypertrophic Cardiomyopathy

• Restoration of sinus rhythm by direct current cardioversion or pharmacological cardioversion is recommended in patients with HCM presenting with recent-onset AF 1
• Oral anticoagulation therapy (INR 2.0–3.0) is recommended in patients with HCM who develop AF unless contraindicated 1
• Amiodarone (or alternatively, disopyramide plus β-blocker) should be considered to achieve rhythm control and maintain sinus rhythm 1

Pulmonary Disease

• Correction of hypoxemia and acidosis is recommended as initial management for patients who develop AF during acute pulmonary illness 1
• Direct current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable due to AF 1
• Theophylline and β-adrenergic agonist agents are not recommended in patients with bronchospastic lung disease who develop AF 1

Common Pitfalls to Avoid

• Underdosing anticoagulation or inappropriate discontinuation increases stroke risk 2
• Using digoxin as the sole agent for rate control in paroxysmal AF is ineffective 1, 2
• Failing to continue anticoagulation after cardioversion in patients with stroke risk factors 2
• Attempting cardioversion without appropriate anticoagulation in patients with AF lasting more than 48 hours 5
• Failing to identify and treat reversible causes of atrial fibrillation, such as thyroid dysfunction or electrolyte abnormalities 5