What oral medications are recommended for a patient with atrial fibrillation?

Oral Medications for Atrial Fibrillation

For patients with atrial fibrillation, oral anticoagulation with a direct oral anticoagulant (DOAC) is the primary medication recommended for stroke prevention, with apixaban, rivaroxaban, edoxaban, or dabigatran preferred over warfarin in most cases, plus rate control agents (beta-blockers or non-dihydropyridine calcium channel blockers) to manage heart rate. 1

Anticoagulation for Stroke Prevention

DOAC Selection and Dosing

Direct oral anticoagulants are recommended over warfarin for most patients with nonvalvular AF due to lower bleeding risks, particularly reduced intracranial hemorrhage. 1, 2

• Apixaban: 5 mg twice daily is the standard dose; reduce to 2.5 mg twice daily if patient has at least 2 of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1, 3

• Rivaroxaban: 20 mg once daily for CrCl >50 mL/min; 15 mg once daily for CrCl 15-50 mL/min 1

• Edoxaban: 60 mg once daily for CrCl >50 mL/min; 30 mg once daily for CrCl 15-50 mL/min; contraindicated if CrCl >95 mL/min 1

• Dabigatran: 150 mg twice daily for CrCl >30 mL/min; 75 mg twice daily for CrCl 15-30 mL/min; contraindicated if CrCl <15 mL/min or on dialysis 1

When to Anticoagulate

Anticoagulation is recommended for patients with a CHA₂DS₂-VASc score ≥2 in men or ≥3 in women, which corresponds to an estimated stroke risk of 2% or greater per year. 1, 2

• For CHA₂DS₂-VASc score of 1 in men or 2 in women, oral anticoagulation is reasonable over no therapy or aspirin 1

• For CHA₂DS₂-VASc score of 0 in men or 1 in women, it is reasonable to omit antithrombotic therapy 1

• Aspirin is not recommended for stroke prevention in AF as it has poorer efficacy than anticoagulation and is not safer. 1, 2

Special Populations

• Mechanical heart valves: Warfarin is required (target INR 2.0-3.0 or 2.5-3.5 depending on valve type and location); DOACs are contraindicated 1

• End-stage renal disease (CrCl <15 mL/min or dialysis): Warfarin (INR 2.0-3.0) is reasonable; apixaban 5 mg or 2.5 mg twice daily may be used based on dose-reduction criteria; dabigatran and edoxaban are contraindicated 1

Rate Control Medications

First-Line Rate Control Agents

Beta-blockers, diltiazem, or verapamil are recommended as first-choice drugs for patients with AF and LVEF >40% to control heart rate and reduce symptoms. 1

For patients with heart failure with reduced ejection fraction (LVEF ≤40%), beta-blockers and/or digoxin are recommended. 1

Specific Agent Dosing

Beta-blockers 1:

• Metoprolol tartrate: 25-200 mg twice daily (oral) or 2.5-5 mg IV bolus
• Metoprolol succinate: 50-400 mg daily
• Carvedilol: 3.125-25 mg twice daily
• Bisoprolol: 2.5-10 mg daily
• Atenolol: 25-100 mg daily (renally eliminated)

Non-dihydropyridine calcium channel blockers 1:

• Diltiazem: 120-360 mg daily (extended-release) or 0.25 mg/kg IV over 2 minutes
• Verapamil: 180-480 mg daily (extended-release) or 5-10 mg IV over ≥2 minutes
• Avoid in patients with HFrEF as they may exacerbate hemodynamic compromise 1

Digoxin 1:

• 0.25-0.5 mg IV loading dose, then maintenance dosing
• Effective for rate control at rest but not during exercise; best used in combination with beta-blockers or calcium channel blockers 1
• Should not be used as sole agent for paroxysmal AF 1

Rhythm Control Medications (Antiarrhythmics)

Early rhythm control with antiarrhythmic drugs or catheter ablation is recommended for symptomatic patients, those with tachycardia-induced cardiomyopathy, or HFrEF to improve quality of life and cardiovascular outcomes. 1, 2

Pharmacological Cardioversion Agents

• Flecainide or propafenone IV: Recommended for recent-onset AF in patients without severe LV hypertrophy, HFrEF, or coronary artery disease 1

• Vernakalant IV: Recommended for recent-onset AF, excluding patients with recent ACS, HFrEF, or severe aortic stenosis 1

• Amiodarone IV or oral: Recommended when cardioversion is desired in patients with severe LV hypertrophy, HFrEF, or coronary artery disease, though cardioversion may be delayed 1

Common Pitfalls to Avoid

• Never discontinue anticoagulation based on bleeding risk scores alone—assess and manage modifiable bleeding risk factors instead 1

• Do not add antiplatelet therapy to oral anticoagulation for stroke prevention—this increases bleeding without additional stroke benefit 1

• Avoid switching between DOACs or from DOAC to warfarin without clear indication, as this does not prevent recurrent embolic stroke 1

• Do not use IV diltiazem or verapamil in patients with decompensated heart failure and AF, as this may worsen hemodynamics 1

• Never use digoxin or calcium channel blockers in AF with pre-excitation (WPW), as they may paradoxically accelerate ventricular response 1

• Ensure therapeutic anticoagulation for at least 3 weeks before elective cardioversion (or perform TEE to exclude thrombus), and continue anticoagulation for at least 4 weeks post-cardioversion regardless of rhythm 1