What is the management of atrial fibrillation (A-fib)?

From the Guidelines

Managing atrial fibrillation (A-fib) requires a comprehensive approach focusing on rate control, rhythm control, stroke prevention, and addressing underlying causes, with the most recent guidelines from 2024 1 emphasizing the importance of rate control therapy as initial treatment. The management of A-fib involves several key components, including:

• Rate control: Medications like beta-blockers (metoprolol 25-100mg twice daily), calcium channel blockers (diltiazem 120-360mg daily), or digoxin (0.125-0.25mg daily) are used to control heart rate, with the goal of reducing symptoms and improving quality of life 1.
• Rhythm control: Antiarrhythmic drugs such as amiodarone (200mg daily after loading), flecainide (50-200mg twice daily), or propafenone may be used to maintain normal sinus rhythm, with the selection of these drugs guided by safety and individual patient characteristics 1.
• Stroke prevention: Anticoagulation therapy is recommended for most patients, with options including warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5mg twice daily), rivaroxaban (20mg daily), or dabigatran (150mg twice daily), and the CHA₂DS₂-VASc score helps determine stroke risk and need for anticoagulation 1.
• Lifestyle modifications: Managing hypertension, treating sleep apnea, reducing alcohol intake, and maintaining a healthy weight are essential for optimal management of A-fib. The 2024 ESC guidelines 1 recommend atrioventricular node ablation combined with cardiac resynchronization therapy in severely symptomatic patients with permanent AF and at least one hospitalization for HF, to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality. Regular monitoring of heart rhythm, medication effectiveness, and anticoagulation levels is necessary for optimal management, with the goal of reducing symptoms, preventing complications, and improving quality of life for patients with A-fib.

From the FDA Drug Label

Oral anticoagulation therapy with warfarin is recommended in patients with persistent or paroxysmal AF (PAF) (intermittent AF) at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age >75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus) In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, but who are at intermediate risk of stroke, antithrombotic therapy with either oral warfarin or aspirin, 325 mg/day, is recommended. The dose of warfarin should be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations.

Management of A-fib:

• For patients with high-risk A-fib, oral anticoagulation therapy with warfarin is recommended.
• For patients with intermediate-risk A-fib (age 65 to 75 years, no other risk factors), antithrombotic therapy with either oral warfarin or aspirin (325 mg/day) is recommended.
• The target INR for warfarin therapy in A-fib patients is 2.0 to 3.0. 2

From the Research

Management of Atrial Fibrillation

Atrial fibrillation (AF) is a common arrhythmia that requires prompt and effective treatment to mitigate systemic resource utilization and improve the quality of life of patients. The management of AF involves two main tenets: prevention of stroke and systemic embolism, and symptom control with either a rate or a rhythm control strategy 3.

Rate Control Strategies

Rate control is a widely used strategy for managing AF, which aims to modulate ventricular rate, alleviate adverse associated symptoms, and improve the quality of life 4. The choice of rate control medication depends on the patient's individual characteristics, underlying heart disease, and haemodynamic impairment. Commonly used rate control medications include:

• Beta-blockers: preferred in patients with myocardial ischemia, myocardial infarction, and hyperthyroidism, but should be avoided in patients with bronchial asthma and chronic obstructive pulmonary disease 5, 6
• Non-dihydropyridine calcium channel blockers: preferred in patients with bronchial asthma and chronic obstructive pulmonary disease 5, 6
• Digoxin: generally less effective in slowing the ventricular rate in acute setting, but can be used in combination with other medications 5, 6

Rhythm Control Strategies

Rhythm control strategies aim to restore and maintain sinus rhythm, and may be preferred in patients with newly diagnosed AF or those who are highly symptomatic 3. Rhythm control can be achieved through antiarrhythmic medications, catheter ablation, or a combination of both.

Factors to Consider

When managing AF, it is essential to consider the following factors:

• Underlying heart disease and haemodynamic impairment 5
• Presence of comorbidities, such as heart failure, bronchial asthma, and chronic obstructive pulmonary disease 5, 6
• Patient's individual characteristics, such as age, symptoms, and quality of life 3, 4
• The need for thromboembolic prophylaxis to prevent stroke and systemic embolism 3

Treatment Options

Treatment options for AF include:

• Pharmacotherapy: beta-blockers, non-dihydropyridine calcium channel blockers, digoxin, and antiarrhythmic medications 3, 4, 5, 6
• Catheter ablation: may be preferred in patients with newly diagnosed AF or those who are highly symptomatic 3
• Atrioventricular node ablation and pacing: may be considered in patients with heart failure or those who are not responsive to pharmacotherapy 4, 5