See atrial fibrillation Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting over 10 million adults in the US, and is associated with increased risks of stroke, heart failure, and mortality.
Management is individualized, focusing on symptom control, stroke prevention, and modification of underlying risk factors.
The evaluation requires confirmation of AF with a 12-lead ECG, assessment of symptoms, and identification of reversible causes.
Baseline laboratory studies:electrolytes, renal and thyroid function, echocardiography, and evaluation for structural heart disease or comorbidities are recommended.
Stroke risk stratification
The CHA₂DS₂-VASc score is used to estimate annual stroke risk and guide anticoagulation decisions.
For most patients with a CHA₂DS₂-VASc score ≥2 (men) or ≥3 (women), oral anticoagulation is recommended.
Direct oral anticoagulants (DOACs)—apixaban, rivaroxaban, edoxaban—are preferred over warfarin due to lower bleeding risk and similar or superior efficacy.
Aspirin is not recommended for stroke prevention in AF. In patients with absolute contraindications to anticoagulation, left atrial appendage occlusion may be considered.
Acute management depends on hemodynamic stability.
Unstable patients with hypotension, shock, ongoing ischemia, or heart failure require urgent electrical cardioversion.
Stable patients should receive rate control and anticoagulation as initial therapy.
Rate control is generally first-line for most patients, especially those who are older or minimally symptomatic.
β-blockers and nondihydropyridine calcium channel blockers-diltiazem, verapamil are preferred; digoxin may be considered in those with heart failure or low activity levels.
The target resting heart rate is <110 bpm for asymptomatic patients and <80 bpm for those with persistent symptoms.
Rhythm control with restoration and maintenance of sinus rhythm is considered in patients with persistent symptoms despite rate control, younger patients, those with heart failure, or those with a first episode of AF.
Rhythm control options include antiarrhythmic drugs, electrical or pharmacologic cardioversion, and catheter ablation.
Early rhythm control may reduce stroke and mortality in select patients.
Lifestyle and risk factor modification is recommended for all patients, including weight loss, regular exercise, blood pressure control, smoking cessation, and reduction of alcohol intake.
Among patients with AF who had undergone implantation of a drug eluting stent at least one year earlier, non-vitamin K anticoagulant monotherapy was non-inferior to combination (anticoagulants plus clopidogrel) therapy for net adverse clinical effects.