management of atrial fibrillation

Last edited 05/2021 and last reviewed 09/2023

AF management comprises of

• therapies with prognostic impact - anticoagulation and treatment of cardiovascular conditions
• therapies predominantly providing symptomatic benefit - rate control and rhythm control (1)

The main goals in the management of atrial fibrillation are:

• urgent control of the ventricular rate during paroxysmal or persistent AF
• restoration of sinus rhythm by pharmacologic or electrical means
• prevention of thromboembolic complications
• prevention of recurrence of AF following successful restoration of sinus rhythm
• long-term rate control in those with permanent AF (2)

The therapeutic interventions may be considered under the following headings:

• general measures
• non-drug management
• drug management

Indications for emergency rhythm control (4):

Patients with ongoing atrial fibrillation at the time of initial evaluation, as confirmed by 12 lead electrocardiography, and

• with very slow or rapid ventricular rates (typically <40 bpm and >150 bpm),
• evidence of hemodynamic instability,
• severe symptoms,
• or decompensated heart failure
  
  
• should be referred to the emergency department for stabilization and possible electrical cardioversion
• in case of unknown duration of atrial fibrillation
  • cardioversion should be preceded by transesophageal echocardiography to rule out intracardiac thrombus
  • patients are required to be on anticoagulation for at least four weeks after electrical cardioversion to reduce the risk of thromboembolism

NICE state (3) rhythm control should be favoured if:

• atrial fibrillation has a reversible cause
• heart failure thought to be primarily caused by atrial fibrillation
• new-onset atrial fibrillation
• atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
• for whom a rhythm-control strategy would be more suitable based on clinical judgement

Ponamgi et al state rhythm control should be favored (4):

• in the presence of significant atrial fibrillation related symptoms or presumed tachycardia induced cardiomyopathy
• may also be preferable in younger (<65 years) patients with paroxysmal atrial fibrillation, as rate control alone is likely to result in progression to longstanding persistent atrial fibrillation over a period of time, which will later be more difficult to control and carries a risk of development of tachycardia induced cardiomyopathy

Reference:

• (1) Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg. 2016;50(5):e1-e88.
• (2) Bajpai A, Savelieva I, Camm AJ. Treatment of atrial fibrillation. Br Med Bull. 2008;88(1):75-94.
• (3) NICE (April 2021). Atrial fibrillation: the management of atrial fibrillation
• (4) Ponamgi SP et al. Screening and management of atrial fibrillation in primary care. BMJ 2021;372:mn379 http://dx.doi.org/10.1136/bmj.mn379