In a hemodynamically stable adult with new‑onset atrial fibrillation (<48 hours), what is the recommended drug regimen for rate control, rhythm conversion, and anticoagulation?

Drug Management of Acute Atrial Fibrillation

For hemodynamically stable adults with new-onset AF (<48 hours), initiate IV beta-blockers (metoprolol) or non-dihydropyridine calcium channel blockers (diltiazem) for rate control, begin anticoagulation immediately based on CHA₂DS₂-VASc score, and consider pharmacologic cardioversion with flecainide, propafenone, or IV ibutilide if rhythm control is desired. 1, 2

Rate Control Strategy

First-line agents for acute rate control:

• IV beta-blockers (metoprolol, esmolol) or IV diltiazem are the drugs of choice for acute rate control in hemodynamically stable patients without pre-excitation. 1 These agents rapidly slow ventricular response within minutes.
• Target resting heart rate <100 bpm initially, though a lenient strategy (<110 bpm) may be reasonable if the patient remains asymptomatic with preserved left ventricular function. 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with decompensated heart failure, as they worsen hemodynamic compromise. 1

Specific dosing from guidelines:

• Metoprolol: 2.5-5 mg IV bolus over 2 minutes, up to 3 doses 1
• Diltiazem: 0.25 mg/kg IV bolus over 2 minutes, then 5-15 mg/h infusion 1
• Esmolol: 500 mcg/kg IV bolus over 1 minute, then 50-300 mcg/kg/min infusion 1

For patients with heart failure or reduced ejection fraction:

• Use beta-blockers and/or digoxin only 2
• IV amiodarone (300 mg over 1 hour, then 10-50 mg/h) can be useful for rate control in critically ill patients without pre-excitation. 1

Critical contraindication:

• In patients with pre-excitation (WPW) and AF, never give digoxin, calcium channel blockers, or IV amiodarone—these may paradoxically increase ventricular response and precipitate ventricular fibrillation. 1 These patients require immediate electrical cardioversion if unstable, or procainamide/ibutilide if stable. 2

Anticoagulation Management

For AF <48 hours duration:

• Calculate CHA₂DS₂-VASc score immediately (1 point each for: CHF, hypertension, age 65-74, diabetes, vascular disease, female sex; 2 points each for: age ≥75, prior stroke/TIA/thromboembolism). 2
• If CHA₂DS₂-VASc ≥2: initiate anticoagulation immediately with IV heparin or low-molecular-weight heparin, followed by direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, or edoxaban. 1, 2 DOACs are preferred over warfarin due to lower intracranial hemorrhage risk. 2
• If CHA₂DS₂-VASc = 1: anticoagulation is reasonable but may be individualized based on bleeding risk. 2
• If CHA₂DS₂-VASc = 0: aspirin or no anticoagulation. 2

For AF ≥48 hours or unknown duration:

• Anticoagulation with warfarin (INR 2.0-3.0) is mandatory for at least 3 weeks before and 4 weeks after cardioversion, regardless of CHADS₂-VASc score or cardioversion method. 1
• Alternative: Perform transesophageal echocardiography (TEE) to exclude left atrial thrombus, then proceed with immediate cardioversion if no thrombus is seen, followed by at least 4 weeks of anticoagulation. 1

Rhythm Control (Pharmacologic Cardioversion)

For patients with AF <48 hours who are hemodynamically stable:

• Flecainide, propafenone, dofetilide, or IV ibutilide are first-line agents for pharmacologic cardioversion in patients without structural heart disease or coronary artery disease. 1
• Amiodarone is reasonable for pharmacologic cardioversion but is not appropriate as initial therapy in healthy patients due to significant organ toxicity risks. 1, 2

Key contraindications:

• Flecainide and propafenone are contraindicated in patients with structural heart disease, coronary artery disease, or left ventricular dysfunction. 3
• In patients with reduced ejection fraction (<35%), amiodarone is the only antiarrhythmic typically recommended. 3

Electrical cardioversion:

• Immediate electrical cardioversion is indicated for hemodynamically unstable patients (hypotension, acute heart failure, ongoing chest pain). 1 Do not delay for anticoagulation in this scenario, but initiate IV heparin concurrently and continue anticoagulation for at least 4 weeks post-cardioversion. 1

Rate vs. Rhythm Control Decision

Rate control plus anticoagulation is the preferred initial strategy for most patients, as landmark trials (AFFIRM, RACE) demonstrated no survival advantage with rhythm control and potentially worse outcomes in some subgroups. 2

Consider rhythm control in specific scenarios:

• Younger patients (<65 years) with symptomatic AF 2
• First episode of AF in otherwise healthy patients 2
• Patients whose quality of life remains significantly compromised despite adequate rate control 2
• Tachycardia-induced cardiomyopathy 1

Common Pitfalls to Avoid

• Never use digoxin as monotherapy for rate control in active patients—it only controls rate at rest and is ineffective during exercise. 2, 3
• Do not use dronedarone for rate control in permanent AF—it increases risk of stroke, MI, and cardiovascular death. 1
• Avoid AV nodal ablation without first attempting pharmacologic rate control. 1
• Do not attempt cardioversion in AF ≥48 hours duration without adequate anticoagulation (3 weeks) or TEE guidance, unless the patient is hemodynamically unstable. 1
• Spontaneous conversion to sinus rhythm occurs in 50-70% of patients with AF <48 hours within 24-48 hours, so a wait-and-see approach with rate control is reasonable before pursuing cardioversion. 2, 4