What is the management of atrial fibrillation (Afib)?

Management of Atrial Fibrillation

The management of atrial fibrillation requires a comprehensive approach focused on stroke prevention with oral anticoagulation, symptom control through rate or rhythm strategies, and addressing underlying causes to reduce morbidity and mortality.

Stroke Prevention

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

Rate Control Strategy

• Beta-blockers, diltiazem, or verapamil are first-line medications for rate control in patients with preserved ejection fraction (LVEF >40%) 1, 2, 4
• Beta-blockers and/or digoxin are recommended for patients with reduced ejection fraction (LVEF ≤40%) 1, 2
• Treatment should aim for a resting heart rate of <100 beats per minute 5
• Digoxin is not recommended as monotherapy for rate control in active patients but may be used in combination with other agents 2, 6, 5
• For patients with obstructive pulmonary disease, non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) are preferred 7, 2
• Beta-1 selective blockers in small doses may be considered as an alternative in patients with obstructive pulmonary disease 7

Rhythm Control Strategy

• Consider rhythm control for symptomatic patients or those with new-onset atrial fibrillation 1, 2, 8
• Electrical cardioversion is recommended for patients with AF causing hemodynamic instability 1, 2
• For pharmacological cardioversion in patients without structural heart disease, flecainide or propafenone can be considered 1, 5
• Amiodarone may be the most effective agent for reducing the occurrence of paroxysmal AF and for preventing recurrence 7
• Catheter ablation should be considered when antiarrhythmic medications fail to control symptoms 1, 2

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 7
• Oral anticoagulation therapy (INR 2.0–3.0) is recommended in patients with HCM who develop AF unless contraindicated 7
• Amiodarone (or alternatively, disopyramide plus β-blocker) should be considered to achieve rhythm control and maintain sinus rhythm 7, 2
• Catheter ablation of AF should be considered in patients with symptomatic AF refractory to pharmacological control 7

Pulmonary Disease

• Correction of hypoxemia and acidosis is recommended as initial management for patients who develop AF during acute pulmonary illness 7, 2
• Direct current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable due to AF 7, 2
• Non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) are preferred for rate control 7, 2
• Theophylline and β-adrenergic agonist agents are not recommended in patients with bronchospastic lung disease who develop AF 7

Wolff-Parkinson-White Syndrome

• Catheter ablation of an overt accessory pathway in patients with AF is recommended to prevent sudden cardiac death 7
• Immediate referral to an experienced ablation center for catheter ablation is recommended for patients who survived sudden cardiac death and have evidence of overt accessory pathway conduction 7

Common Pitfalls to Avoid

• Underdosing anticoagulation or inappropriate discontinuation increases stroke risk 1, 2
• Using digoxin as the sole agent for rate control in paroxysmal AF is ineffective 2, 6, 5
• Failing to continue anticoagulation after cardioversion in patients with stroke risk factors 1, 2
• Attempting cardioversion without appropriate anticoagulation in patients with AF lasting more than 48 hours 1, 2
• It may be desirable to reduce the dose of digoxin for 1-2 days prior to electrical cardioversion to avoid inducing ventricular arrhythmias 6
• Failing to identify and treat reversible causes of atrial fibrillation, such as thyroid dysfunction or electrolyte abnormalities 2