Management Options for Atrial Fibrillation
The management of atrial fibrillation should focus on stroke prevention through anticoagulation and symptom control using either rate or rhythm control strategies, with direct oral anticoagulants (DOACs) being preferred over vitamin K antagonists for most patients. 1, 2
Initial Assessment
- Perform electrocardiogram to confirm diagnosis, assess ventricular rate, and identify structural abnormalities 1, 2
- Evaluate for associated conditions including hypertension, heart failure, diabetes, obesity, sleep apnea, and alcohol intake 1, 2
- Obtain transthoracic echocardiogram to identify valvular disease, left atrial size, and left ventricular function 1, 2
- Complete blood tests for thyroid, renal, and hepatic function to identify potential reversible causes 1, 2
Stroke Prevention Strategy
- Assess stroke risk using CHA₂DS₂-VA score to guide anticoagulation decisions 1, 2
- Initiate oral anticoagulation for all eligible patients with CHA₂DS₂-VA score ≥2 1, 2
- Choose DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) over vitamin K antagonists 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 2, 3
- Anticoagulate patients with AF lasting >48 hours or of unknown duration for at least 3-4 weeks before and after cardioversion 2, 3
- Continue anticoagulation according to stroke risk regardless of whether the patient is in AF or sinus rhythm 1, 2
Rate Control Strategy
- Use beta-blockers or non-dihydropyridine calcium channel antagonists (diltiazem, verapamil) as first-line therapy for patients with preserved ejection fraction (LVEF >40%) 1, 2
- Administer beta-blockers and/or digoxin for patients with reduced ejection fraction (LVEF ≤40%) 1, 2
- Consider combination therapy with digoxin and a beta-blocker or calcium channel antagonist for better rate control both at rest and during exercise 1, 2
- Avoid using digoxin as the sole agent for rate control in paroxysmal AF as it is ineffective 2
- For patients with pulmonary disease, consider non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) 1
Rhythm Control Strategy
- Consider rhythm control for symptomatic patients or those with new-onset AF 1, 2
- Perform immediate electrical cardioversion for patients with hemodynamic instability 1, 2
- For pharmacological cardioversion in patients without structural heart disease, consider flecainide or propafenone 1
- For patients with abnormal left ventricular function but LVEF >35%, consider sotalol or amiodarone 1
- For patients with LVEF <35%, amiodarone is generally the only recommended medication 1
- Consider catheter ablation as a second-line option if antiarrhythmic drugs fail to control AF, or as a first-line option in patients with paroxysmal AF 1, 2
Special Considerations
- For patients with mechanical prosthetic heart valves, warfarin is recommended with target INR based on valve type and position 3
- For patients with bioprosthetic valves in the mitral position, warfarin with a target INR of 2.5 (range 2.0-3.0) is recommended 3
- For patients undergoing cardiac surgery, consider oral beta-blockers to prevent postoperative AF 2
- For patients with Wolff-Parkinson-White syndrome and AF, catheter ablation of the accessory pathway is recommended 2
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 2
- Performing catheter ablation without prior trial of medical therapy 1
- Failing to continue anticoagulation after cardioversion in patients with stroke risk factors 1, 2
- Administering type IC antiarrhythmic drugs in patients with AF in the setting of acute myocardial infarction 2