From the Guidelines
Management of new onset atrial fibrillation (AF) should focus on the AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment. This approach is based on the most recent guidelines from the European Society of Cardiology (ESC) 1. The initial evaluation should include medical history, assessment of symptoms and their impact, blood tests, echocardiography/other imaging, patient-reported outcome measures, and risk factors for thromboembolism and bleeding.
Key considerations in the management of new onset AF include:
- Assessing the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score, with reassessment at periodic intervals to assist in decisions on anticoagulant prescription 1
- Using oral anticoagulants for all eligible patients, except those at low risk of incident stroke or thromboembolism, with direct oral anticoagulants (DOACs) preferred over vitamin K antagonists (VKAs) unless the patient has mechanical heart valves or mitral stenosis 1
- Implementing rate control therapy using beta-blockers, digoxin, or diltiazem/verapamil as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms 1
- Considering rhythm control in all suitable AF patients, with a discussion of the potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity 1
The choice of anticoagulant and dose should be based on the patient's individual risk factors and clinical characteristics, with full standard doses of DOACs used unless the patient meets specific dose-reduction criteria, and VKAs dosed to maintain an INR of 2.0-3.0 1.
Long-term management of AF should include addressing underlying causes such as hypertension, sleep apnea, or thyroid disease, and considering catheter ablation for recurrent symptomatic AF despite medical therapy 1, 2. This approach prioritizes morbidity, mortality, and quality of life as the primary outcomes, and is based on the most recent and highest quality evidence available.
From the Research
Management of New Onset Atrial Fibrillation
- New onset atrial fibrillation (NOAF) is a common arrhythmia affecting critically unwell patients, which can lead to worsening haemodynamic compromise, heart failure, thromboembolic events, and increased mortality 3.
- The management of NOAF involves non-pharmacological and pharmacological strategies, including direct current cardioversion, amiodarone, β-adrenergic receptor antagonists, calcium channel blockers, digoxin, magnesium, and other less commonly used agents 3.
- A systematic review and narrative synthesis of 30 studies, including 4 RCTs and 26 observational studies, reported the efficacy of these management strategies, with cardioversion rates ranging from 18% to 96% for amiodarone and 40% to 92% for β-antagonists 3.
Pharmacological Management
- Amiodarone was found to be more effective than diltiazem (odds ratio [OR]=1.91, P=0.32) at cardioversion, while short-acting β-antagonists esmolol and landiolol were more effective compared with diltiazem for cardioversion (OR=3.55, P=0.04) and HR control (OR=3.2, P<0.001) 3.
- Beta blockers (BB) and calcium channel blockers (CCB) are commonly used for rate control, with BB found to decrease the heart rate faster than CCB (5 hours vs. 8 hours, P = 0.009) and shorten the duration of hospitalization in patients with new-onset AF (median 72 vs. 96 hours, P = 0.012) 4.
- The selection between BB and CCB depends on personal preference, and the choice of medication should be guided by efficacy, convenience, cost, and safety considerations 5.
Clinical Considerations
- The definition of successful cardioversion and heart rate control varies between studies, making comparisons between studies and interventions difficult 3.
- Future RCTs are needed to compare individual anti-arrhythmic agents, particularly magnesium, amiodarone, and β-antagonists, and to study the role of anticoagulation in critically unwell patients 3.
- A core outcome dataset for studies of new onset atrial fibrillation is urgently needed to allow comparisons between different anti-arrhythmic strategies 3.