What medications are used to treat atrial fibrillation (Afib)?

Medications for Atrial Fibrillation Management

For patients with atrial fibrillation, the primary medication categories include anticoagulants for stroke prevention, rate control agents to manage heart rate, and antiarrhythmic drugs for rhythm control, with selection based on patient characteristics and comorbidities. 1, 2

Stroke Prevention Medications

• Direct oral anticoagulants (DOACs) are recommended as first-line therapy for stroke prevention in patients with nonvalvular atrial fibrillation and elevated stroke risk (CHA₂DS₂-VA score ≥2) 1, 2
• Apixaban (5 mg twice daily or 2.5 mg twice daily for patients with ≥2 of: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) has demonstrated superiority to warfarin in reducing stroke and systemic embolism with lower bleeding risk 3
• Other commonly used DOACs include dabigatran, edoxaban, and rivaroxaban 2
• Vitamin K antagonists (warfarin) with a target INR of 2.0-3.0 are recommended for patients with mechanical heart valves or moderate-to-severe mitral stenosis 1, 2
• Oral anticoagulation should be continued for at least 4 weeks after cardioversion and long-term in patients with thromboembolic risk factors regardless of whether sinus rhythm is maintained 1

Rate Control Medications

• Beta-1 selective blockers (e.g., metoprolol) or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are recommended as first-line therapy for rate control in patients with preserved ejection fraction (LVEF >40%) 2
• Beta-blockers and/or digoxin are recommended for patients with reduced ejection fraction (LVEF ≤40%) 2, 4
• Diltiazem can be administered at 60-120 mg three times daily (or 120-360 mg in extended-release form) 2
• Verapamil can be administered at 40-120 mg three times daily (or 120-480 mg in extended-release form) 2
• Digoxin (0.0625-0.25 mg daily) may be used in combination with beta-blockers for better rate control both at rest and during exercise 2, 4

Rhythm Control Medications (Antiarrhythmic Drugs)

For Acute Cardioversion of Recent-Onset AF:

• Intravenous flecainide or propafenone is recommended for pharmacological cardioversion of recent-onset AF in patients without severe left ventricular hypertrophy, heart failure with reduced ejection fraction (HFrEF), or coronary artery disease 1
• Intravenous vernakalant is recommended for pharmacological cardioversion of recent-onset AF in patients without recent acute coronary syndrome, HFrEF, or severe aortic stenosis 1
• Intravenous amiodarone is recommended for cardioversion in patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease, though cardioversion may be delayed 1

For Long-term Maintenance of Sinus Rhythm:

• Amiodarone is recommended for patients with AF and HFrEF requiring long-term antiarrhythmic therapy, with careful monitoring for extracardiac toxicity 1
• Dronedarone is recommended for patients requiring long-term rhythm control, including those with heart failure with mid-range ejection fraction (HFmrEF), heart failure with preserved ejection fraction (HFpEF), ischemic heart disease, or valvular disease 1
• Flecainide or propafenone is recommended for patients requiring long-term rhythm control without impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease 1

Special Considerations

• Antiarrhythmic drugs are not recommended in patients with advanced conduction disturbances unless antibradycardia pacing is provided 1
• In pregnancy, beta-1 selective blockers are recommended for heart rate control, excluding atenolol 1
• Digoxin should be considered for heart rate control in pregnancy if beta-blockers are ineffective or not tolerated 1
• In patients with congenital heart disease and AF, oral anticoagulation should be considered regardless of other thromboembolic risk factors 1

Common Pitfalls to Avoid

• Pharmacological cardioversion should not be attempted in patients with sinus node dysfunction, atrioventricular conduction disturbances, or prolonged QTc (>500 ms) without considering risks for proarrhythmia and bradycardia 1
• Early cardioversion without appropriate anticoagulation or transesophageal echocardiography is not recommended if AF duration is longer than 24 hours 1
• Using digoxin as the sole agent for rate control in paroxysmal AF is often ineffective 2
• Underdosing anticoagulation or inappropriate discontinuation significantly increases stroke risk 2

Non-Pharmacological Options

• Catheter ablation is recommended for patients with paroxysmal or persistent AF resistant or intolerant to antiarrhythmic drug therapy 1
• Catheter ablation may be considered as a first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal AF 1
• Catheter ablation is recommended in patients with AF and HFrEF with high probability of tachycardia-induced cardiomyopathy 1