Atrial Fibrillation Management

Initial Assessment

The European Society of Cardiology recommends confirming diagnosis with electrocardiogram to document the arrhythmia 3
Assess for underlying causes including hypertension, heart failure, diabetes, thyroid dysfunction, and valvular disease 2
Perform echocardiogram to identify structural abnormalities and assess left ventricular function 3
Evaluate stroke risk using CHA₂DS₂-VA score to guide anticoagulation decisions 2

The American Heart Association recommends oral anticoagulation for all atrial fibrillation patients with stroke risk factors to prevent thromboembolism 1, 2
Direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban are preferred over vitamin K antagonists due to lower risk of intracranial hemorrhage 1
For patients on warfarin, maintain INR between 2.0-3.0 with weekly monitoring during initiation and monthly when stable 2
Patients with AF lasting >48 hours or of unknown duration require at least 3-4 weeks of anticoagulation before and after cardioversion 1

Beta-blockers, diltiazem, or verapamil are first-line medications for rate control in patients with preserved ejection fraction (LVEF >40%) 1, 2
Beta-blockers and/or digoxin are recommended for patients with reduced ejection fraction (LVEF ≤40%) 1
A combination of digoxin with a beta-blocker or calcium channel antagonist may provide better rate control both at rest and during exercise 2
For patients with obstructive pulmonary disease, non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) are preferred 1

Consider rhythm control for symptomatic patients or those with new-onset atrial fibrillation 2
Electrical cardioversion is recommended for patients with AF causing hemodynamic instability 1, 2
For pharmacological cardioversion in patients without structural heart disease, flecainide or propafenone can be considered 2
Catheter ablation should be considered when antiarrhythmic medications fail to control symptoms 1, 2

Continue anticoagulation according to stroke risk factors regardless of whether the patient is in atrial fibrillation or sinus rhythm 2
Regularly reassess therapy and evaluate for new modifiable risk factors 2
Monitor anticoagulation therapy appropriately: weekly during initiation for vitamin K antagonists and monthly when stable 2
Address modifiable risk factors such as hypertension, obesity, sleep apnea, and alcohol intake 2

Underdosing anticoagulation or inappropriate discontinuation increases stroke risk 1
Using digoxin as the sole agent for rate control in paroxysmal AF is ineffective 1
Failing to continue anticoagulation after cardioversion in patients with stroke risk factors 1
Attempting cardioversion without appropriate anticoagulation in patients with AF lasting more than 48 hours 1

For patients with hypertrophic cardiomyopathy, restoration of sinus rhythm and oral anticoagulation are recommended 1
In patients with pulmonary disease, correction of hypoxemia and acidosis is important in initial management 1