Atrial Fibrillation Management

Core Treatment Strategy

Atrial fibrillation management requires simultaneous implementation of three pillars: anticoagulation for stroke prevention, rate or rhythm control for symptom management, and treatment of underlying conditions—with anticoagulation being non-negotiable for eligible patients. 1, 2

Stroke Prevention: Anticoagulation (First Priority)

Risk Stratification

Calculate CHA₂DS₂-VASc score immediately for every AF patient 3, 1
- Score ≥2 in males or ≥3 in females: Initiate anticoagulation (Class I recommendation) 3
- Score 1 in males or 2 in females: Consider anticoagulation 3
- Score 0 in males or 1 in females: No antithrombotic therapy needed 3

Anticoagulant Selection

Choose Direct Oral Anticoagulants (DOACs) over warfarin as first-line therapy due to lower intracranial hemorrhage risk and no routine monitoring requirements 3, 1, 2
Standard DOAC regimens 1, 2:
- Apixaban 5 mg twice daily (reduce to 2.5 mg twice daily if ≥2 of: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL) 1
- Rivaroxaban 20 mg once daily 4
- Edoxaban or dabigatran at standard doses 1

Warfarin Exceptions

Use warfarin (not DOACs) for mechanical heart valves or moderate-to-severe mitral stenosis 1
Target INR 2.0-3.0 with weekly monitoring during initiation, monthly when stable 3, 1

Critical Anticoagulation Principles

Continue anticoagulation based on stroke risk regardless of whether patient is in AF or sinus rhythm 1, 2
Avoid combining anticoagulants with antiplatelet agents unless specifically indicated (e.g., acute coronary syndrome) 1
Manage modifiable bleeding risk factors (hypertension control, minimize NSAID/antiplatelet duration, moderate alcohol, treat anemia), but never withhold anticoagulation based on bleeding risk scores alone 3, 1

Rate Control Strategy

First-Line Rate Control Agents

For preserved ejection fraction (LVEF >40%):

Beta-blockers (metoprolol, esmolol) OR non-dihydropyridine calcium channel blockers (diltiazem, verapamil) as first-line 3, 1, 5
Diltiazem: 60-120 mg three times daily (or 120-360 mg extended release) 1
Verapamil: 40-120 mg three times daily (or 120-480 mg extended release) 1

For reduced ejection fraction (LVEF ≤40%):

Beta-blockers and/or digoxin 3, 1, 6
Digoxin: 0.0625-0.25 mg daily 1
Avoid non-dihydropyridine calcium channel blockers in heart failure 5

Rate Control Targets

Lenient rate control (resting heart rate <110 bpm) is acceptable initial approach unless symptoms persist 3, 1
If symptoms continue with lenient control, target strict control (<80 bpm at rest) while avoiding bradycardia 3

Combination Therapy

Digoxin plus beta-blocker or calcium channel blocker provides superior control at rest and during exercise compared to monotherapy 1, 6

Special Populations for Rate Control

COPD/active bronchospasm: Use diltiazem or verapamil; avoid beta-blockers, sotalol, and propafenone 1, 6
Thyrotoxicosis or high catecholamine states: Prefer beta-blockers 1, 6
Wolff-Parkinson-White with pre-excited AF: NEVER use AV nodal blockers (adenosine, digoxin, diltiazem, verapamil, amiodarone)—they can precipitate ventricular fibrillation 1, 6

Rhythm Control Strategy

Indications for Rhythm Control

Symptomatic patients despite adequate rate control 3, 2
New-onset AF 1, 2
Heart failure with reduced ejection fraction (HFrEF) where AF may be contributing to decompensation 1, 6

Immediate Cardioversion (Electrical)

Perform urgent electrical cardioversion for: 3, 1, 2, 6

Hemodynamic instability (hypotension, ongoing ischemia, severe heart failure)
Pre-excited AF in Wolff-Parkinson-White syndrome

Elective Cardioversion Protocol

For AF duration >48 hours or unknown duration: 3, 1, 6

Ensure therapeutic anticoagulation for minimum 3 weeks before cardioversion
Continue anticoagulation for minimum 4 weeks after cardioversion (longer if stroke risk factors present)
Alternative: Perform transesophageal echocardiography to exclude left atrial thrombus, then proceed with cardioversion if negative

Long-Term Antiarrhythmic Drug Selection

Algorithm based on cardiac structure: 1, 2

No structural heart disease:

First-line: Flecainide, propafenone, or sotalol 3, 1

Coronary artery disease (without heart failure):

First-line: Sotalol 1

Heart failure or LVEF ≤40%:

Only safe options: Amiodarone or dofetilide 1

Hypertension without left ventricular hypertrophy:

Flecainide or propafenone acceptable 1

Hypertrophic cardiomyopathy:

Amiodarone (or disopyramide plus beta-blocker) 3

Catheter Ablation

Consider as second-line option if antiarrhythmic drugs fail 3, 2
May be considered as first-line in paroxysmal AF 1
In Wolff-Parkinson-White with symptomatic AF: Catheter ablation of accessory pathway is definitive treatment (95% efficacy) 3, 1, 6

Special Clinical Scenarios

Hypertrophic Cardiomyopathy with AF

Immediate direct current cardioversion for recent-onset AF (Class I) 3
Mandatory anticoagulation (INR 2.0-3.0) unless contraindicated (Class I) 3
Amiodarone or disopyramide plus beta-blocker for rhythm control 3

Postoperative AF

Perioperative oral beta-blockers for prevention 3, 2
Rate control with beta-blocker or non-dihydropyridine calcium channel blocker if AF develops 6
Cardioversion if symptomatic 3

AF with Rapid Ventricular Response

IV beta-blockers (metoprolol) or IV diltiazem/verapamil for LVEF >40% 6
IV beta-blockers ± digoxin for LVEF ≤40% 6
Emergency cardioversion for hemodynamic instability 6

Initial Diagnostic Workup

Mandatory baseline assessments: 1, 2

12-lead ECG to confirm AF, assess ventricular rate, identify structural abnormalities
Transthoracic echocardiogram for valvular disease, left atrial size, LV function
Blood tests: Thyroid function, renal function, hepatic function
Chest X-ray to assess for pulmonary edema or lung disease 1

Critical Pitfalls to Avoid

Never underdose or inappropriately discontinue anticoagulation—this dramatically increases stroke risk 1, 2
Never use digoxin as sole agent for paroxysmal AF rate control—it is ineffective 1, 2
Never use AV nodal blockers in Wolff-Parkinson-White with pre-excited AF—risk of ventricular fibrillation 1, 6
Never perform catheter ablation without prior trial of medical therapy (except in specific circumstances like WPW) 1
Never discontinue anticoagulation after cardioversion in patients with stroke risk factors 1, 6
Never use non-dihydropyridine calcium channel blockers in heart failure with reduced ejection fraction 5

Lifestyle and Risk Factor Modification

Maintain optimal blood pressure with ACE inhibitors or ARBs as first-line 2
Target BMI 20-25 kg/m² 2
Exercise: 150-300 minutes/week moderate intensity or 75-150 minutes/week vigorous aerobic activity 2
Moderate alcohol consumption 3
Screen for and treat obstructive sleep apnea 1

Follow-Up and Reassessment

At each visit, systematically evaluate: 2

Has stroke risk profile changed? (Reassess CHA₂DS₂-VASc)
Are symptoms adequately controlled?
Monitor for proarrhythmia with antiarrhythmic drugs
Renal function at least annually with DOACs (more frequently if clinically indicated) 1

What are the management options for atrial fibrillation (Afib)?

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