What are the treatment options for atrial fibrillation (AF)?

Treatment Options for Atrial Fibrillation

The comprehensive management of atrial fibrillation requires both stroke prevention through anticoagulation and symptom control through either rate or rhythm control strategies, with direct oral anticoagulants (DOACs) preferred over vitamin K antagonists for most patients. 1

Stroke Prevention Strategy

• Oral anticoagulation is recommended for all AF patients with stroke risk factors (CHA₂DS₂-VA score ≥2) to prevent thromboembolic events 1, 2
• DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) are preferred over vitamin K antagonists (VKAs) due to lower risk of intracranial hemorrhage, except in patients with mechanical heart valves or mitral stenosis 1, 2
• For patients on warfarin, maintain INR between 2.0-3.0 with weekly monitoring during initiation and monthly when stable 3
• Avoid combining anticoagulants with antiplatelet agents unless specifically indicated (e.g., acute vascular event) 1
• Modifiable bleeding risk factors should be managed, but bleeding risk scores should not be used to decide on starting or withholding anticoagulation 1

Rate Control Strategy

• Rate control is recommended as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy 1
• First-line medications for rate control in patients with preserved ejection fraction (LVEF >40%) include:
  • Beta-blockers (any ejection fraction) 1, 2
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) (LVEF >40% only) 1, 2
  • Digoxin (any ejection fraction) 1, 2
• For patients with reduced ejection fraction (LVEF ≤40%), use beta-blockers and/or digoxin 1, 2
• Combination therapy may be considered if a single drug does not control symptoms or heart rate 1, 4
• Lenient rate control (heart rate <110 bpm) is an acceptable initial approach unless symptoms require stricter control 1, 5
• For patients unresponsive to medication, atrioventricular node ablation with pacemaker implantation should be considered 1

Rhythm Control Strategy

• Rhythm control should be considered in all suitable AF patients, particularly for symptom reduction and quality of life improvement 1, 2
• Immediate electrical cardioversion is recommended for patients with hemodynamic instability 1
• For pharmacological cardioversion or maintenance of sinus rhythm, options include:
  • Flecainide or propafenone for patients without structural heart disease 2, 6
  • Amiodarone for patients with structural heart disease 5, 6
  • Sotalol for patients without significant structural heart disease 5, 6
• Catheter ablation should be considered as:
  • Second-line option if antiarrhythmic drugs fail to control AF 1, 2
  • First-line option in patients with paroxysmal AF 1
• Endoscopic or hybrid ablation should be considered if catheter ablation fails 1
• Continue anticoagulation according to stroke risk regardless of whether the patient is in AF or sinus rhythm 1

Special Considerations

• For patients with WPW syndrome and pre-excited AF:
  • Prompt direct-current cardioversion is recommended for hemodynamically compromised patients 1
  • Avoid administering amiodarone, adenosine, digoxin, or non-dihydropyridine calcium channel antagonists as they can accelerate ventricular rate 1
• For patients with pulmonary disease:
  • Non-dihydropyridine calcium channel antagonists are preferred for rate control 1, 2
  • Beta-1 selective blockers in small doses may be considered as an alternative 2
• For patients with AF and heart failure:
  • Beta-blockers and/or digoxin are recommended for rate control 1
  • Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent 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 physically active patients with paroxysmal AF is often ineffective 2, 4
• Performing catheter ablation without prior trial of medical therapy in most cases 2
• Discontinuing anticoagulation after successful rhythm control in patients with stroke risk factors 1, 2
• Administering antiarrhythmic drugs to patients with advanced conduction disturbances without antibradycardia pacing 1