How do you treat atrial fibrillation (AF)?

From the Guidelines

To treat fast atrial fibrillation (AF), the initial approach should involve controlling the heart rate with medications such as beta-blockers, diltiazem, verapamil, or digoxin, as recommended in the 2024 ESC guidelines for the management of atrial fibrillation 1.

Key Considerations

• The choice of medication depends on the patient's left ventricular ejection fraction (LVEF) and symptoms.
• For patients with LVEF >40%, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms 1.
• Atrioventricular node ablation combined with cardiac resynchronization therapy may be considered in severely symptomatic patients with permanent AF and at least one hospitalization for heart failure to reduce symptoms, physical limitations, recurrent heart failure hospitalization, and mortality 1.

Treatment Approach

• The treatment approach should prioritize controlling the heart rate to reduce symptoms and prevent complications.
• Anticoagulation is crucial to prevent stroke, and the choice of anticoagulant should be based on the patient's stroke risk and bleeding risk.
• The 2016 ESC guidelines for the management of atrial fibrillation recommend initiating anticoagulation in all patients with documented AF/atrial flutter who have an increased risk of stroke, and stroke risk evaluation should be based on the CHADS-VASc score 1.

Medications

• Beta-blockers, such as metoprolol, can be used to control heart rate, with a typical dose of 25-50mg orally twice daily or 5-10mg IV.
• Diltiazem, with a typical dose of 30-60mg orally four times daily or 0.25mg/kg IV, or digoxin, with a typical dose of 0.25mg orally daily or 0.5mg IV loading dose, can also be used to control heart rate.
• Antiarrhythmic drugs, such as amiodarone or flecainide, may be used to convert the rhythm back to normal sinus rhythm, but their use should be guided by safety and efficacy considerations 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Atrial Fibrillation

• Rate control and rhythm control are two main treatment strategies for atrial fibrillation (AF) 2, 3.
• Rate control is often considered the initial treatment for patients with AF, especially those with heart failure, as it is simpler and relatively easier to achieve than rhythm control 2.
• The goal of rate control is to reduce the ventricular rate to a target of below 80-90 bpm at rest 4.

Medications for Rate Control

• Calcium channel blockers (e.g., diltiazem) and beta-blockers (e.g., metoprolol) are commonly used for rate control in AF 5, 4, 6.
• Diltiazem has been shown to achieve rate control faster than metoprolol in some studies 5, 6.
• The choice of medication for rate control should be based on individual patient characteristics, including the presence of underlying heart disease and hemodynamic impairment 4.

Non-Pharmacological Options

• Catheter ablation (CA) is a non-pharmacological option for rate control in AF, but its indications and appropriateness need to be carefully examined in each individual 2.
• Left atrial appendage closure and the maze procedure are other non-pharmacological options for AF treatment 3.

Considerations for Treatment

• The treatment of AF should be individualized based on the patient's clinical characteristics, including the presence of heart failure, and the severity of symptoms 2, 4.
• The choice of treatment should also consider the potential risks and benefits of each option, as well as the patient's preferences and values 3.