What is the best management approach for an adult patient with chronic atrial fibrillation (Afib) and a history of cardiovascular disease or other risk factors?

Chronic Atrial Fibrillation Management

For adults with chronic atrial fibrillation and cardiovascular disease, implement the AF-CARE pathway: anticoagulation based on stroke risk (DOACs preferred), rate control with beta-blockers or non-dihydropyridine calcium channel blockers, aggressive comorbidity management, and consider rhythm control for symptomatic patients. 1

Initial Assessment and Risk Stratification

Confirm diagnosis with 12-lead ECG and obtain transthoracic echocardiogram to assess left ventricular ejection fraction (LVEF), left atrial size, and valvular disease 1. Complete blood tests for thyroid, renal, and hepatic function to identify reversible causes 2.

Calculate CHA₂DS₂-VA score immediately to stratify stroke risk 1:

• Score ≥2: Anticoagulation strongly recommended 1
• Score = 1: Anticoagulation should be considered 1
• Additional high-risk conditions (hypertrophic cardiomyopathy, cardiac amyloidosis): Anticoagulate regardless of score 1

Anticoagulation Strategy (Priority #1)

Direct oral anticoagulants (DOACs) are preferred over warfarin except in mechanical heart valves and mitral stenosis 1, 3. Options include:

• Rivaroxaban 20 mg once daily (15 mg if CrCl 30-50 mL/min) 4
• Apixaban 5 mg twice daily (2.5 mg if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL) 2
• Dabigatran or edoxaban per standard dosing 1

For warfarin therapy: Maintain INR 2.0-3.0, monitor weekly during initiation then monthly when stable, ensure time in therapeutic range >70% 1, 2. Switch from warfarin to DOAC if poor INR control or high intracranial hemorrhage risk 1.

Critical: Avoid combining anticoagulants with antiplatelet agents unless acute vascular event or specific procedural indication 1. Antiplatelet monotherapy is not recommended as stroke prevention 1.

Rate Control Strategy

For LVEF >40% (Preserved Ejection Fraction)

Initiate beta-blocker, diltiazem, or verapamil as first-line therapy 1, 2, 3:

• Metoprolol or atenolol (beta-blockers) 2
• Diltiazem 60-120 mg TID (or 120-360 mg extended release) 2
• Verapamil 40-120 mg TID (or 120-480 mg extended release) 2

Target resting heart rate <110 bpm (lenient control), with stricter control if symptoms persist 1. If monotherapy inadequate, combine beta-blocker with digoxin (avoiding bradycardia) 1, 2.

For LVEF ≤40% (Reduced Ejection Fraction)

Initiate beta-blocker or digoxin 1, 2:

• Beta-blockers preferred due to mortality benefit in heart failure 1, 2
• Digoxin 0.0625-0.25 mg daily 2
• Avoid diltiazem/verapamil in reduced ejection fraction 1, 2

If rate control fails despite combination therapy, evaluate for AV node ablation with pacemaker 1. For severely symptomatic patients with heart failure hospitalization, consider AV node ablation with cardiac resynchronization therapy (CRT) 1.

Emergency Rate Control

For acute hemodynamic instability: Immediate synchronized cardioversion 1, 2. For stable acute AF with rapid ventricular response: IV beta-blockers (esmolol 0.5 mg/kg bolus, then 0.05-0.25 mg/kg/min) or IV diltiazem 1, 2. In heart failure with congestion, use IV digoxin or amiodarone (300 mg IV over 30-60 minutes) 1, 2.

Comorbidity and Risk Factor Management

Blood pressure control is mandatory to reduce AF recurrence and progression 1. Optimize heart failure therapy including:

• SGLT2 inhibitors for all AF patients with heart failure regardless of ejection fraction to reduce hospitalization and cardiovascular death 1
• Diuretics for congestion 1
• Guideline-directed medical therapy for reduced ejection fraction 1

Achieve glycemic control in diabetes to reduce AF burden and recurrence 1. Target ≥10% weight loss in overweight/obese patients 1. Reduce alcohol to ≤3 standard drinks (≤30 grams) per week 1. Screen for obstructive sleep apnea (not with questionnaires alone) and treat if present 1.

Rhythm Control Considerations

Consider rhythm control for: symptomatic patients despite adequate rate control, younger patients with new-onset AF, rate-related cardiomyopathy, or hemodynamically unstable patients 1, 2, 3, 5.

Cardioversion Protocol

For AF duration <48 hours**: May proceed with cardioversion after initiating anticoagulation 2. **For AF duration >48 hours or unknown: Require 3 weeks therapeutic anticoagulation before cardioversion and minimum 4 weeks after 1, 2. Alternative: transesophageal echocardiography to exclude thrombus, then early cardioversion with short-term anticoagulation 3.

Continue anticoagulation long-term based on stroke risk regardless of rhythm status 1, 2, 3—most strokes occur after anticoagulation stopped or with subtherapeutic levels 3.

Antiarrhythmic Drug Selection

Selection based strictly on cardiac structure and LVEF 2:

No structural heart disease: Flecainide, propafenone, or sotalol 2, 3

Coronary artery disease with LVEF >35%: Sotalol first-line 2

Heart failure or LVEF ≤35%: Amiodarone only safe option 2, 3

Hypertension without LVH: Flecainide or propafenone 2

Sotalol requires hospitalization with continuous ECG monitoring for minimum 3 days and dose adjustment based on creatinine clearance 2.

Catheter Ablation

Consider as second-line when antiarrhythmic drugs fail, or as first-line in paroxysmal AF 1, 2, 3. Success rates up to 80% after one or two treatments, superior to pharmacotherapy 6. Continue anticoagulation after ablation based on stroke risk 3.

Special Populations

Wolff-Parkinson-White with pre-excited AF: Avoid AV nodal blockers (adenosine, digoxin, diltiazem, verapamil, beta-blockers)—can precipitate ventricular fibrillation 2. Immediate DC cardioversion if unstable; IV procainamide or ibutilide if stable 2. Definitive treatment: catheter ablation of accessory pathway 2.

COPD/active bronchospasm: Avoid beta-blockers; use diltiazem or verapamil 2, 3.

Postoperative AF: Beta-blocker unless contraindicated; preoperative amiodarone reduces incidence in high-risk cardiac surgery 1, 2.

Ongoing Evaluation

Reassess every 6 months initially, then annually: ECG, blood tests, cardiac imaging as needed 1. Assess AF symptom impact before and after treatment changes 1. Reassess stroke risk periodically to ensure appropriate anticoagulation 1. Monitor renal function at least annually with DOACs, more frequently if clinically indicated 2.

Critical Pitfalls to Avoid

Never discontinue anticoagulation based on rhythm status alone—stroke risk persists regardless of sinus rhythm 1, 2, 3, 4. Never use digoxin as sole agent in paroxysmal AF—ineffective for rate control during episodes 2. Never combine beta-blockers with diltiazem/verapamil without specialist guidance and ambulatory ECG monitoring for bradycardia 1. Never perform AV node ablation without pharmacological trial first 1. Never use IV non-dihydropyridine calcium channel blockers or IV beta-blockers in decompensated heart failure 1.