Initial Management of Atrial Fibrillation
Rate control with chronic anticoagulation is the recommended initial management strategy for most patients with newly detected atrial fibrillation. 1, 2
Initial Assessment
- Perform an electrocardiogram to confirm atrial fibrillation diagnosis, assess ventricular rate, and identify underlying structural abnormalities 2
- Obtain a transthoracic echocardiogram to identify valvular heart disease, left atrial size, left ventricular function, and potential structural abnormalities 2
- Complete blood tests for thyroid, renal, and hepatic function to identify potential reversible causes 2
Stroke Prevention Strategy
- Assess stroke risk using the CHA₂DS₂-VA score to guide anticoagulation decisions 2
- Initiate oral anticoagulation for all eligible patients with a CHA₂DS₂-VA score ≥2 2
- Choose direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban over vitamin K antagonists (VKAs) except in patients with mechanical heart valves or mitral stenosis 2, 3
- For patients on warfarin, maintain an INR between 2.0-3.0 with weekly monitoring during initiation and monthly when stable 2
Rate Control Strategy
- For patients with preserved ejection fraction (LVEF >40%), administer beta-blockers or non-dihydropyridine calcium channel antagonists (diltiazem, verapamil) as first-line therapy 2, 4
- For patients with reduced ejection fraction (LVEF ≤40%), use beta-blockers and/or digoxin 2
- Digoxin is only effective for rate control at rest and should only be used as a second-line agent 1, 2
- The following drugs are recommended for their demonstrated efficacy in rate control during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil 1, 5
Hemodynamic Assessment
- Determine hemodynamic stability in patients with AF and rapid ventricular response 6
- For patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control, perform immediate direct-current cardioversion 6
- Anticoagulation should be initiated concurrently if AF duration is >48 hours or unknown 6
Rhythm Control Considerations
- Consider rhythm control strategy for symptomatic patients or those with new-onset atrial fibrillation 2
- Both direct-current cardioversion and pharmacological conversion are appropriate options for patients who elect to undergo acute cardioversion 1
- Ensure therapeutic anticoagulation for at least 3 weeks before scheduled cardioversion if atrial fibrillation duration is >24 hours or unknown 2
- Continue oral anticoagulation for at least 4 weeks after cardioversion, and long-term in patients with stroke risk factors regardless of rhythm status 2
Special Clinical Scenarios
- For patients with AF and COPD, use non-dihydropyridine calcium channel antagonists and avoid beta-blockers if active bronchospasm is present 6
- For patients with AF and acute coronary syndrome, use intravenous beta-blockers if no contraindications exist 6
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 2, 7
- Failing to continue anticoagulation after cardioversion in patients with stroke risk factors 2
- Most patients converted to sinus rhythm from atrial fibrillation should not be placed on rhythm maintenance therapy since the risks outweigh the benefits 1
Long-term Management
- Periodically reassess therapy and evaluate for new modifiable risk factors 2
- Continue anticoagulation according to the patient's stroke risk regardless of whether they are in atrial fibrillation or sinus rhythm 2, 8
- Consider catheter ablation as a second-line option if antiarrhythmic drugs fail to control atrial fibrillation 2