What is the initial management and treatment approach for a patient with atrial fibrillation in Indian clinical practice?

Atrial Fibrillation Management in Indian Clinical Practice

IPD (Inpatient) Prescription

For newly diagnosed or symptomatic atrial fibrillation requiring admission, immediate assessment and initiation of rate control with anticoagulation forms the cornerstone of management. 1, 2

Initial Assessment & Investigations

• ECG to confirm AF diagnosis, assess ventricular rate, and identify structural abnormalities 1, 2
• 2D Echo to evaluate left atrial size, left ventricular function, valvular disease, and structural abnormalities 1, 2
• Blood tests: Complete blood count, renal function (serum creatinine), liver function tests, thyroid function (TSH, T3, T4), electrolytes (Na+, K+), and blood glucose 1, 2
• Chest X-ray to assess for pulmonary edema or underlying lung disease 3

Hemodynamic Status Assessment

If patient presents with hemodynamic instability (symptomatic hypotension, ongoing chest pain, acute pulmonary edema, shock, or altered mental status), perform immediate synchronized DC cardioversion at 120-200 joules biphasic without waiting for anticoagulation. 4

For stable patients, proceed with medical management as outlined below. 1, 2

Rate Control Strategy (First-Line for Stable Patients)

For patients with preserved ejection fraction (LVEF >40%):

• Tab. Metoprolol 25-50 mg PO TDS OR
• Tab. Diltiazem 60 mg PO TDS (or 120-180 mg SR BD) OR
• Tab. Verapamil 40-80 mg PO TDS (or 120-240 mg SR BD) 1

For patients with reduced ejection fraction (LVEF ≤40%) or heart failure:

• Tab. Metoprolol 25 mg PO BD (start low, titrate up) AND/OR
• Tab. Digoxin 0.25 mg PO OD (loading: 0.5 mg stat, then 0.25 mg after 6 hours, then 0.25 mg OD maintenance) 1

Target heart rate: <110 bpm at rest (lenient control) is acceptable if patient remains asymptomatic; <80 bpm (strict control) if symptomatic 1

Anticoagulation Strategy

Calculate CHA₂DS₂-VASc score immediately: 1, 2

• Congestive heart failure (1 point)
• Hypertension (1 point)
• Age ≥75 years (2 points)
• Diabetes mellitus (1 point)
• Stroke/TIA/thromboembolism history (2 points)
• Vascular disease (1 point)
• Age 65-74 years (1 point)
• Sex category female (1 point)

For CHA₂DS₂-VASc score ≥2 (or ≥1 in males), initiate oral anticoagulation: 1, 2

First-line choice - Direct Oral Anticoagulants (DOACs):

• Tab. Apixaban 5 mg PO BD (preferred) 1, 5
  • Reduce to 2.5 mg BD if patient has ANY 2 of: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL 1, 5
• Tab. Rivaroxaban 20 mg PO OD with evening meal (alternative) 1
• Tab. Dabigatran 150 mg PO BD (alternative) 1

Second-line choice - Vitamin K Antagonist (if DOACs contraindicated or mechanical valve/mitral stenosis present):

• Tab. Warfarin 5 mg PO OD (adjust dose to maintain INR 2.0-3.0) 1, 6
• Check INR weekly during initiation, then monthly when stable 1, 6

If AF duration >48 hours or unknown duration and cardioversion planned:

• Administer therapeutic anticoagulation for minimum 3 weeks before cardioversion 1, 2, 4
• Continue anticoagulation for minimum 4 weeks post-cardioversion 1, 4
• Long-term anticoagulation continues based on CHA₂DS₂-VASc score regardless of rhythm 1

Additional Medications

For acute rate control in emergency (if oral route not feasible):

• Inj. Metoprolol 2.5-5 mg IV slow over 2 minutes, repeat every 5 minutes up to 15 mg OR
• Inj. Diltiazem 0.25 mg/kg IV over 2 minutes, then infusion 5-15 mg/hour 1

Avoid in hemodynamically unstable patients - use DC cardioversion instead. 4

Special Considerations for Indian Practice

For patients with COPD or active bronchospasm:

• Avoid beta-blockers 3, 1
• Use Tab. Diltiazem 60 mg PO TDS as first-line rate control 3, 1
• Beta-1 selective blockers (bisoprolol) in small doses may be considered cautiously if diltiazem insufficient 3

For patients with Wolff-Parkinson-White syndrome (pre-excited AF):

• Never use AV nodal blockers (digoxin, diltiazem, verapamil, adenosine, amiodarone) - they can precipitate ventricular fibrillation 1, 4
• Immediate DC cardioversion if unstable 1, 4
• If stable: Inj. Procainamide IV 1

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OPD (Outpatient) Prescription

For stable patients with chronic AF or follow-up after initial management, continue rate control and anticoagulation with regular monitoring. 1, 2

Chronic Rate Control Maintenance

For preserved LVEF (>40%):

• Tab. Metoprolol 25-50 mg PO BD/TDS OR
• Tab. Diltiazem SR 120-180 mg PO BD OR
• Tab. Verapamil SR 120-240 mg PO BD 1

For reduced LVEF (≤40%):

• Tab. Metoprolol 25-50 mg PO BD AND/OR
• Tab. Digoxin 0.0625-0.25 mg PO OD 1

Combination therapy (if monotherapy inadequate):

• Tab. Digoxin 0.125-0.25 mg PO OD PLUS Tab. Metoprolol 25 mg PO BD provides better control at rest and during exercise 1

Long-term Anticoagulation

Continue based on CHA₂DS₂-VASc score (≥2 or ≥1 in males): 1, 2

DOAC (preferred):

• Tab. Apixaban 5 mg PO BD (or 2.5 mg BD if dose-reduction criteria met) 1, 5
• Tab. Rivaroxaban 20 mg PO OD with food 1
• Tab. Dabigatran 150 mg PO BD 1

Warfarin (if DOAC not suitable):

• Tab. Warfarin 2-5 mg PO OD (adjust to INR 2.0-3.0) 6
• Monthly INR monitoring when stable 1, 6

Monitoring Schedule

• Renal function testing: Annually for DOAC patients, more frequently if creatinine clearance <60 mL/min 1
• Liver function tests: Annually 1
• Thyroid function: Annually, especially if on amiodarone 1
• ECG: Every 3-6 months 1
• 2D Echo: Annually or if clinical status changes 1

Lifestyle Modifications (Critical for All Patients)

• Weight loss if BMI >27 kg/m² 1
• Regular exercise (moderate intensity 150 minutes/week) 1
• Alcohol restriction (<100 g/week) 1
• Blood pressure control (target <130/80 mmHg) 1
• Diabetes control (HbA1c <7%) 1
• Obstructive sleep apnea screening and treatment 1

When to Consider Rhythm Control

Rhythm control with antiarrhythmic drugs or catheter ablation should be considered for: 1, 2

• Highly symptomatic patients despite adequate rate control 1, 2
• New-onset AF (<12 months) 1
• Young patients (<65 years) without structural heart disease 1
• AF-induced cardiomyopathy (tachycardia-mediated) 1

Antiarrhythmic drug selection (if rhythm control chosen):

For patients WITHOUT structural heart disease:

• Tab. Flecainide 50-100 mg PO BD OR
• Tab. Propafenone 150-300 mg PO TDS 1

For patients WITH coronary artery disease but LVEF >35%:

• Tab. Sotalol 80-160 mg PO BD OR
• Tab. Amiodarone 200 mg PO OD (after loading) 1

For patients WITH heart failure or LVEF ≤35%:

• Tab. Amiodarone 200 mg PO OD (only safe option) 1
• Loading: 600-800 mg/day for 1 week, then 400 mg/day for 1 week, then 200 mg/day maintenance 1

Critical Pitfalls to Avoid

• Never discontinue anticoagulation after cardioversion in patients with stroke risk factors - continue based on CHA₂DS₂-VASc score regardless of rhythm 1, 4
• Never use digoxin as sole agent for rate control in paroxysmal AF - ineffective during exercise 1
• Never combine anticoagulants with antiplatelet agents unless specific indication (e.g., recent ACS) - increases bleeding risk 1
• Never use AV nodal blockers in pre-excited AF (WPW syndrome) - can cause ventricular fibrillation 1, 4
• Never use non-selective beta-blockers, sotalol, or propafenone in patients with active bronchospasm 3, 1
• Never underdose DOACs - use full standard doses unless specific reduction criteria met 1

Follow-up Schedule

• First visit: 2 weeks after initiation (assess rate control, symptoms, medication tolerance)
• Subsequent visits: Monthly for first 3 months, then every 3 months if stable 1
• Annual comprehensive assessment: ECG, echo, renal function, liver function, thyroid function 1