What is the recommended treatment for atrial fibrillation?

Management of Atrial Fibrillation

For stable atrial fibrillation, initiate beta-blockers (metoprolol 25-100 mg twice daily) or nondihydropyridine calcium channel blockers (diltiazem 120-360 mg daily or verapamil 120-360 mg daily) as first-line rate control, target heart rate <80-90 bpm at rest, and start anticoagulation with a direct oral anticoagulant (apixaban, rivaroxaban, edoxaban, or dabigatran) for stroke prevention in patients with CHA₂DS₂-VASc score ≥2. 1, 2

Rate Control Strategy

First-Line Agents for Stable Patients

• Beta-blockers or nondihydropyridine calcium channel blockers are the cornerstone of rate control therapy. 1, 2

• For patients with preserved ejection fraction (LVEF >40%), choose from:

  • Metoprolol 25-100 mg twice daily orally 1
  • Atenolol per guideline dosing 1
  • Diltiazem 120-360 mg daily in divided doses 1
  • Verapamil 120-360 mg daily in divided doses 1

• For patients with reduced ejection fraction (LVEF ≤40%), use beta-blockers and/or digoxin only—avoid calcium channel blockers due to negative inotropic effects. 2, 3

• Target resting heart rate <80-90 bpm for strict control, or <110 bpm for lenient control if patients remain asymptomatic with preserved left ventricular function. 1, 3

Second-Line and Combination Therapy

• Digoxin is only effective for rate control at rest and should be reserved as a second-line agent for patients with heart failure, left ventricular dysfunction, or sedentary individuals. 1

• Combination therapy with digoxin plus a beta-blocker or calcium channel blocker provides superior control both at rest and during exercise compared to monotherapy. 4, 1

• Digoxin dosing: 0.0625-0.25 mg daily. 3

Special Population Considerations

• In patients with COPD or active bronchospasm, use diltiazem or verapamil instead of beta-blockers to avoid bronchospasm. 4, 3

• In thyrotoxicosis, beta-blockers are first-line unless contraindicated; use nondihydropyridine calcium channel blockers if beta-blockers cannot be used. 4

• In acute coronary syndrome with severe left ventricular dysfunction or hemodynamic instability, consider amiodarone or digoxin cautiously. 4

• In Wolff-Parkinson-White syndrome with pre-excited AF, avoid all AV nodal blockers (beta-blockers, calcium channel blockers, digoxin, adenosine, amiodarone) as they can accelerate ventricular rate through the accessory pathway and precipitate ventricular fibrillation. 4, 3

When Pharmacologic Rate Control Fails

• AV nodal ablation with permanent pacing is reasonable when pharmacological therapy is insufficient, not tolerated, or when tachycardia-mediated cardiomyopathy is suspected. 1, 2

• Do not perform AV node ablation without first attempting pharmacological rate control. 4

Anticoagulation for Stroke Prevention

Risk Stratification and Initiation

• Use the CHA₂DS₂-VASc score to assess stroke risk: initiate anticoagulation for scores ≥2, consider for score of 1. 2, 3

• CHA₂DS₂-VASc scoring: Congestive heart failure (1 point), Hypertension (1 point), Age ≥75 years (2 points), Diabetes (1 point), Stroke/TIA/thromboembolism history (2 points), Vascular disease (1 point), Age 65-74 years (1 point), Sex category female (1 point). 3

Anticoagulant Selection

• Direct oral anticoagulants (DOACs) are preferred over warfarin in most patients due to superior safety profile and reduced risk of intracranial hemorrhage. 1, 2

• DOAC options include apixaban, dabigatran, edoxaban, or rivaroxaban at full standard doses unless specific dose-reduction criteria are met. 2, 3

• Apixaban dosing: 5 mg twice daily, or 2.5 mg twice daily if patient meets dose-reduction criteria (any 2 of 3: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL). 3

• For patients with mechanical heart valves or moderate-to-severe mitral stenosis, warfarin remains the only recommended option. 2

• Warfarin dosing: Individualized to maintain INR 2.0-3.0, with weekly monitoring during initiation and monthly when stable. 3, 5

• Monitor renal function at least annually when using DOACs, more frequently if clinically indicated. 3

Critical Anticoagulation Pitfalls

• Do not combine anticoagulants with antiplatelet agents unless specifically indicated (e.g., acute vascular event). 3

• Assess and manage modifiable bleeding risk factors, but do not use bleeding risk scores to withhold anticoagulation in appropriate candidates. 2, 3

• Continue anticoagulation according to stroke risk regardless of whether the patient is in atrial fibrillation or sinus rhythm. 3

Rhythm Control Considerations

When to Pursue Rhythm Control

• Consider rhythm control when:
  • Patient symptoms significantly affect quality of life 1
  • Poor exercise tolerance despite adequate rate control 1
  • New-onset AF (within 12 months of diagnosis) to reduce cardiovascular death or hospitalization 2
  • Heart failure with reduced ejection fraction, as catheter ablation improves quality of life, left ventricular function, and cardiovascular outcomes 6

Cardioversion Approach

• Immediate electrical cardioversion is indicated for hemodynamically unstable patients. 2, 3

• For scheduled cardioversion with AF duration >48 hours or unknown duration, provide at least 3 weeks of therapeutic anticoagulation before the procedure. 2, 3, 5

• Continue oral anticoagulation for at least 4 weeks after cardioversion in all patients, and long-term in those with stroke risk factors. 2, 3

• DOACs are preferred over warfarin for patients undergoing cardioversion. 2

Antiarrhythmic Drug Selection

• Most patients converted to sinus rhythm should not be placed on rhythm maintenance therapy. 1

• For patients without structural heart disease, use flecainide, propafenone, or sotalol as first-line options. 1, 3

• For patients with coronary artery disease without heart failure, sotalol is preferred. 3

• For patients with heart failure or LVEF ≤40%, amiodarone or dofetilide are the only safe options due to proarrhythmic risk of other antiarrhythmics. 3

• For patients with hypertension without left ventricular hypertrophy, flecainide and propafenone may be used. 3

Catheter Ablation

• Catheter ablation is first-line therapy for symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. 6

• Catheter ablation is recommended for patients with AF and heart failure with reduced ejection fraction to improve quality of life, left ventricular function, and reduce mortality and heart failure hospitalization rates. 6

• Consider catheter ablation as second-line when antiarrhythmic drugs fail to control symptoms. 3

• In Wolff-Parkinson-White syndrome with symptomatic pre-excited AF, catheter ablation of the accessory pathway is recommended, especially if the pathway has a short refractory period. 4

Acute Management of AF with Rapid Ventricular Response

Hemodynamically Unstable Patients

• Perform immediate electrical cardioversion for patients with hemodynamic instability. 4, 2

Hemodynamically Stable Patients

• For emergency rate control with preserved left ventricular function, use:

  • IV diltiazem (60-120 mg three times daily, or 120-360 mg extended release) 3, 7
  • IV esmolol (0.5 mg/kg bolus over 1 minute, then 0.05-0.25 mg/kg/min infusion) 3, 7

• For patients with heart failure without accessory pathway, use IV digoxin or amiodarone (300 mg IV diluted in 250 mL of 5% glucose over 30-60 minutes). 4, 3

• In Wolff-Parkinson-White syndrome with stable pre-excited AF, use IV procainamide or ibutilide—never use AV nodal blockers. 4

Monitoring and Follow-Up

• Assess rate control adequacy at rest, during exercise using exercise testing, and with 24-hour Holter monitoring. 1

• Evaluate heart rate during exercise and adjust pharmacological treatment in symptomatic patients during activity. 4

• Periodically reassess therapy and evaluate for new modifiable risk factors. 3

• Address lifestyle and risk factor modification at all stages: treat hypertension, heart failure, diabetes, obesity, obstructive sleep apnea, physical inactivity, and high alcohol intake. 2, 3