From the Guidelines
The principle of management of Atrial Fibrillation (Afib) is to follow the AF-CARE pathway, which includes: [C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, and [E] Evaluation and dynamic reassessment 1.
Key Components of Management
- Comorbidity and risk factor management: thorough evaluation and management of conditions associated with AF, such as hypertension, heart failure, diabetes mellitus, obesity, obstructive sleep apnoea, physical inactivity, and high alcohol intake 1.
- Avoid stroke and thromboembolism: use of oral anticoagulants, such as DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban), which are preferred over VKAs (warfarin and others), except in patients with mechanical heart valves and mitral stenosis 1.
- Reduce symptoms by rate and rhythm control: use of beta-blockers, digoxin, or diltiazem/verapamil for rate control, and consideration of rhythm control therapy, including electrical or pharmacological cardioversion, antiarrhythmic drugs, and catheter or surgical ablation, to reduce symptoms and morbidity 1.
- Evaluation and dynamic reassessment: periodic reassessment of therapy and attention to new modifiable risk factors to slow/reverse the progression of AF, increase quality of life, and prevent adverse outcomes 1.
Anticoagulation Therapy
- CHA2DS2-VA score: use of this score to assess the risk of thromboembolism and guide anticoagulant prescription, with anticoagulation recommended for patients with a score of 2 or higher 1.
- DOACs vs VKAs: DOACs are preferred over VKAs due to their improved safety and efficacy profile, except in patients with mechanical heart valves and mitral stenosis 1.
Rhythm Control Therapy
- Indications: rhythm control therapy is indicated for symptom improvement in patients with AF, and may be considered as first-line or second-line therapy, depending on patient characteristics and preferences 1.
- Options: electrical or pharmacological cardioversion, antiarrhythmic drugs, catheter or surgical ablation, and AF surgery or ablation and pacing 1.
From the Research
Principle of Management of Atrial Fibrillation (Afib)
The management of Atrial Fibrillation (Afib) can be organized into several key principles, including:
- Risk stratification and treatment of heart failure
- Stroke prevention
- Symptom control, which can be further divided into rate control and rhythm control 2
- The ABC Pathway, which includes "A" avoid stroke with anticoagulation, "B" for better symptom management with patient-centered, symptom-directed decisions on rate or rhythm control, and "C" cardiovascular and comorbidity risk reduction, including lifestyle factors and psychological morbidity 3
Rate Control vs Rhythm Control
The decision between rate control and rhythm control depends on the patient's clinical status, the duration of Afib, and the experience of the treating physician 4.
- Rate control is the preferred management option in most patients, with a goal of achieving a resting heart rate of less than 80 beats per minute, although a more lenient rate control of less than 110 beats per minute may be acceptable in some cases 5
- Rhythm control is an option for patients in whom rate control cannot be achieved or who have persistent symptoms despite rate control 5
Anticoagulation Therapy
Anticoagulation therapy is an essential component of Afib management, with warfarin being superior to aspirin and clopidogrel in preventing stroke, despite its narrow therapeutic range and increased risk of bleeding 5, 6.