Treatment of Atrial Fibrillation
For most patients with atrial fibrillation, initial management should focus on rate control with beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) combined with anticoagulation based on stroke risk, as this strategy offers equivalent mortality outcomes to rhythm control with fewer adverse effects and hospitalizations. 1, 2
Anticoagulation Strategy (First Priority)
Stroke prevention takes precedence over all other treatment decisions. 1
Assess stroke risk using CHA₂DS₂-VASc score: Initiate anticoagulation for scores ≥2, and consider for scores ≥1. 1, 3
Direct oral anticoagulants (DOACs) are preferred over warfarin due to lower intracranial hemorrhage risk. Options include apixaban, dabigatran, edoxaban, or rivaroxaban. 1, 4
- Apixaban dosing: 5 mg twice daily (or 2.5 mg twice daily if patient meets ≥2 of these criteria: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL). 1
Warfarin is reserved for mechanical heart valves or moderate-to-severe mitral stenosis. 1, 5
Continue anticoagulation regardless of whether sinus rhythm is restored, as silent AF recurrences are common and stroke risk persists. 1, 3
Avoid aspirin alone or aspirin plus clopidogrel—these provide inferior stroke prevention with similar bleeding risk. 4
Rate Control Strategy (Initial Approach for Most Patients)
Rate control is the preferred initial strategy for most patients, particularly those over 65 years or with coronary disease, as landmark trials demonstrate no mortality benefit from rhythm control. 2, 6
For Patients with Preserved Ejection Fraction (LVEF >40%)
Beta-blockers (metoprolol, esmolol) or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are first-line. 1, 3
Beta-blockers are preferred in high catecholamine states (acute illness, post-operative, thyrotoxicosis). 7
Combination therapy (digoxin plus beta-blocker or calcium channel blocker) may be needed for better rate control during exercise. 1
For Patients with Reduced Ejection Fraction (LVEF ≤40%)
Beta-blockers and/or digoxin are recommended. 1, 3
- Digoxin: 0.0625-0.25 mg daily. 1
Avoid diltiazem and verapamil in heart failure with reduced ejection fraction—they worsen hemodynamic compromise. 3
Rate Control Targets
Lenient rate control (resting heart rate <110 bpm) is acceptable initially unless symptoms persist. 1, 3
Strict rate control (resting heart rate <80 bpm) is reserved for patients with ongoing symptoms despite lenient control. 1
Rhythm Control Strategy (Selected Patients)
Consider rhythm control for: 1, 3
- Younger patients (<65 years) with symptomatic AF despite adequate rate control
- New-onset AF in otherwise healthy patients
- Hemodynamically unstable patients (immediate electrical cardioversion required)
- Heart failure patients where AF may be contributing to decompensation
Acute Cardioversion
Immediate electrical cardioversion is mandatory for hemodynamic instability (hypotension, acute heart failure, ongoing chest pain). 7, 1
For AF >48 hours or unknown duration: Ensure 3 weeks of therapeutic anticoagulation before elective cardioversion, and continue for at least 4 weeks after (indefinitely if stroke risk factors present). 1, 5
Pharmacological cardioversion options: 1, 3
- Flecainide or propafenone for patients without structural heart disease
- Amiodarone for patients with structural heart disease or reduced LVEF
- Amiodarone IV: 300 mg diluted in 250 mL 5% glucose over 30-60 minutes for emergencies. 1
Long-term Antiarrhythmic Drug Selection
Selection depends on underlying cardiac structure: 1
No structural heart disease: Flecainide, propafenone, or sotalol are first-line due to lower toxicity. 1
Coronary artery disease without heart failure: Sotalol is preferred. 1
Heart failure or LVEF ≤40%: Amiodarone or dofetilide are the only safe options due to proarrhythmic risk of other agents. 1
Hypertension without left ventricular hypertrophy: Flecainide or propafenone may be used. 1
Catheter Ablation
Consider as second-line therapy when antiarrhythmic drugs fail, or as first-line in selected patients with paroxysmal AF. 1, 3
AV node ablation with pacemaker implantation is reserved for patients unresponsive to intensive rate and rhythm control. 3
Special Populations
Wolff-Parkinson-White (WPW) Syndrome with Pre-excited AF
Immediate DC cardioversion if hemodynamically unstable. 7
IV procainamide or ibutilide if stable. 7
Catheter ablation of accessory pathway is definitive treatment for symptomatic patients. 7
NEVER use AV nodal blockers (adenosine, digoxin, diltiazem, verapamil, amiodarone)—these accelerate ventricular rate and can precipitate ventricular fibrillation. 7
Chronic Obstructive Pulmonary Disease
Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are preferred for rate control. 7, 3
Avoid non-selective beta-blockers, sotalol, propafenone, and adenosine in patients with bronchospasm. 7
Treat underlying lung disease and correct hypoxia first—cardioversion may be ineffective until respiratory status improves. 7
Critical Pitfalls to Avoid
Discontinuing anticoagulation after successful cardioversion in patients with stroke risk factors—AF recurrence is often silent. 3, 4
Using digoxin as monotherapy in active patients—it only controls rate at rest, not during exercise. 4
Combining anticoagulants with antiplatelet agents without specific indication (e.g., recent acute coronary syndrome)—this increases bleeding risk unnecessarily. 1
Using amiodarone as first-line therapy in young, healthy patients—reserve for refractory cases due to significant organ toxicity. 4
Underdosing DOACs or using inappropriate dose reductions—follow specific criteria for dose adjustment. 1
Withdrawing anticoagulation based on bleeding risk scores alone—these should guide risk factor modification, not anticoagulation decisions. 1, 3
Evidence Comparison: Rate vs. Rhythm Control
The AFFIRM trial (4060 patients) demonstrated that rhythm control offers no survival advantage over rate control (5-year mortality 23.8% vs 21.3%, p=0.08), with rhythm control causing more hospitalizations and adverse drug effects. 2, 6 This landmark study established rate control as the preferred initial strategy for most patients, particularly those over 65 or with coronary disease. 2