From the Guidelines
Atrial fibrillation treatment should prioritize rhythm control, with catheter ablation being a first-line therapy in selected patients.
Key Recommendations
- Rhythm control is recommended for patients with reduced LV function and persistent or high-burden atrial fibrillation, as it may improve LV function 1.
- Catheter ablation receives a Class 1 indication as first-line therapy in selected patients, including those with paroxysmal atrial fibrillation and a low risk profile for procedure-associated complications 1.
- Rate control therapy is recommended in patients with atrial fibrillation, using beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs to control heart rate and reduce symptoms 1.
- Anticoagulation should be initiated in all patients with documented atrial fibrillation and an increased risk of stroke, with the CHADS-VASc score guiding stroke risk evaluation 1.
- Left atrial appendage occlusion devices receive a higher level Class of Recommendation (2a) for use in patients with long-term contraindications to anticoagulation 1.
Patient Selection
- Patients with paroxysmal atrial fibrillation, no or minimal structural heart disease, and a low CHA2DS2-VASc score are suitable candidates for catheter ablation 1.
- Patients with persistent or longstanding-persistent atrial fibrillation may benefit from rhythm control therapy, including electrical or pharmacological cardioversion, long-term antiarrhythmic drug therapy, or catheter ablation 1.
Important Considerations
- Bleeding risks during anticoagulation therapy should be minimized by identifying modifiable bleeding risk factors, such as hypertension, concomitant antiplatelet or NSAID therapy, and anaemia 1.
- Ventricular rate should be initially reduced according to a lenient target heart rate (<110 beats/min at rest), with a lower heart rate attempted if symptoms persist, while avoiding bradycardia 1.
From the Research
Treatment Recommendations for Atrial Fibrillation
The latest recommendations for the treatment of atrial fibrillation (AF) include:
- Lifestyle and risk factor modification to prevent AF onset, recurrence, and complications, as recommended by the 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline 2
- Anticoagulation with a vitamin K antagonist or direct oral anticoagulant for patients with an estimated risk of stroke and thromboembolic events of 2% or greater per year, with direct oral anticoagulants preferred over warfarin due to lower bleeding risks 2
- Early rhythm control with antiarrhythmic drugs or catheter ablation for select patients with AF, including those with symptomatic paroxysmal AF or heart failure with reduced ejection fraction (HFrEF) 2, 3, 4, 5
Rhythm Control and Catheter Ablation
- Catheter ablation is recommended as a first-line therapy for patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF 2, 5
- Pulmonary vein isolation is now also recommended as a first-line treatment for paroxysmal AF 5
- Rhythm control using antiarrhythmic drugs or catheter ablation can improve prognosis in select patients with AF 3, 4
Stroke Prevention and Anticoagulation
- The CHA2DS2-VASc score has been simplified to the CHA2DS2-VA score for the risk assessment of thromboembolism 5
- Anticoagulation is recommended for patients with an estimated risk of stroke and thromboembolic events of 2% or greater per year, with direct oral anticoagulants preferred over warfarin due to lower bleeding risks 2, 3, 4, 5
- Aspirin is not recommended for stroke prevention in patients with AF due to poorer efficacy compared to anticoagulation 2