What are the initial management strategies for atrial fibrillation (Afib) rhythm control?

Initial Management Strategies for Atrial Fibrillation Rhythm Control

Rhythm control should be considered in all suitable AF patients to reduce symptoms and morbidity, with the primary indication being reduction in AF-related symptoms and improvement in quality of life, and for selected patient groups, sinus rhythm maintenance can reduce morbidity and mortality. 1

Safety and Anticoagulation First

Before pursuing any rhythm control strategy, anticoagulation is paramount:

• Delay cardioversion and provide at least 3 weeks of anticoagulation beforehand if AF duration is >24 hours to prevent thromboembolic complications 1
• Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in eligible patients undergoing cardioversion 1
• Continue anticoagulation according to the patient's individual risk of thromboembolism (CHA2DS2-VA score), irrespective of whether they are in AF or sinus rhythm after successful rhythm control 1

Acute Cardioversion Approach

Hemodynamically Unstable Patients

• Use immediate electrical cardioversion in cases of haemodynamic instability (hypotension, ongoing myocardial ischemia, angina, or heart failure) 1, 2, 3

Hemodynamically Stable Patients

• Choose between electrical or pharmacological cardioversion based on patient characteristics and preferences 1
• A wait-and-see approach for spontaneous conversion within 48 hours of AF onset should be considered in patients without haemodynamic compromise as an alternative to immediate cardioversion 1

Pharmacological Cardioversion Options

For patients WITHOUT structural heart disease:

• Intravenous flecainide is recommended when rapid cardioversion of recent-onset AF is desired, excluding patients with recent ACS, HFrEF, or severe aortic stenosis 1
• Flecainide or propafenone can be used for long-term rhythm control, excluding those with impaired left ventricular systolic function, severe left ventricular hypertrophy, or coronary artery disease 1

For patients WITH structural heart disease (HFrEF, coronary artery disease, severe LV hypertrophy):

• Intravenous amiodarone is recommended, accepting there may be a delay in cardioversion 1
• Amiodarone is recommended for long-term antiarrhythmic drug therapy to prevent recurrence and progression of AF, with careful consideration and monitoring for extracardiac toxicity 1

For patients with HFmrEF, HFpEF, ischemic heart disease, or valvular disease:

• Dronedarone is recommended for long-term rhythm control to prevent recurrence and progression of AF 1

Long-Term Rhythm Control Strategy

Timing of Implementation

• Implementation of a rhythm control strategy should be considered within 12 months of diagnosis in selected patients with AF at risk of thromboembolic events to reduce the risk of cardiovascular death or hospitalization 1

Catheter Ablation Indications

Second-line option:

• Catheter ablation is recommended in patients with paroxysmal or persistent AF resistant or intolerant to antiarrhythmic drug therapy to reduce symptoms, recurrence, and progression of AF 1

First-line option:

• Catheter ablation is recommended as a first-line option within a shared decision-making rhythm control strategy in patients with paroxysmal AF to reduce symptoms, recurrence, and progression of AF 1, 4
• This represents a paradigm shift, as catheter ablation can now be offered before antiarrhythmic drug trials in symptomatic paroxysmal AF 5

Heart failure patients:

• AF catheter ablation is recommended in patients with AF and HFrEF with high probability of tachycardia-induced cardiomyopathy to reverse left ventricular dysfunction 1
• Catheter ablation improves quality of life, left ventricular systolic function, and cardiovascular outcomes including mortality and heart failure hospitalization rates in HFrEF patients 5

Anticoagulation During Ablation

• Initiate oral anticoagulation at least 3 weeks prior to catheter-based ablation in AF patients at elevated thromboembolic risk 1
• Uninterrupted oral anticoagulation is recommended during AF catheter ablation 1
• Continue oral anticoagulation for at least 2 months after AF ablation in all patients, irrespective of rhythm outcome or CHA2DS2-VA score 1
• After 2 months, continue anticoagulation according to the patient's CHA2DS2-VA score, not the perceived success of the ablation procedure 1

Rate Control as Adjunct to Rhythm Control

Even when pursuing rhythm control, rate control medications remain essential:

• Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with LVEF >40% 1, 2
• For patients with LVEF ≤40%, use beta-blockers and/or digoxin only; avoid non-dihydropyridine calcium channel blockers 2, 3
• Rate control serves as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy 1

Critical Contraindications and Safety Considerations

Avoid pharmacological cardioversion in:

• Patients with sinus node dysfunction, atrioventricular conduction disturbances, or prolonged QTc (>500 ms), unless risks for proarrhythmia and bradycardia have been considered 1
• Patients with advanced conduction disturbances unless antibradycardia pacing is provided 1

In Wolff-Parkinson-White syndrome:

• Avoid beta-blockers, calcium channel blockers, digoxin, and adenosine as they can precipitate ventricular fibrillation 3
• Use IV procainamide or ibutilide instead for pre-excited AF 3

Repeat Ablation for Recurrence

• Repeat AF catheter ablation should be considered in patients with AF recurrence after initial catheter ablation, provided symptoms were improved after the initial pulmonary vein isolation or after failed initial PVI 1

Surgical Ablation

• Concomitant surgical ablation is recommended in patients undergoing mitral valve surgery and AF suitable for a rhythm control strategy, with shared decision-making supported by an experienced team 1
• Endoscopic and hybrid ablation procedures should be considered if catheter ablation fails, or as an alternative to catheter ablation in persistent AF despite antiarrhythmic drugs 1

Common Pitfalls to Avoid

• Never withdraw anticoagulation based on successful rhythm control—stroke risk is determined by CHA2DS2-VA score, not rhythm status 1
• Do not use class I antiarrhythmics (flecainide, propafenone) in structural heart disease—this can cause life-threatening proarrhythmia 1, 4
• Do not cardiovert without adequate anticoagulation or TEE if AF duration >24 hours 1
• Monitor for extracardiac toxicity with amiodarone, particularly thyroid, pulmonary, and hepatic complications 1