Atrial Fibrillation Management

Initial Assessment and Diagnosis

The American College of Cardiology recommends confirming diagnosis with 12-lead ECG to document the arrhythmia, assess ventricular rate, QRS duration, QT interval, and identify underlying structural abnormalities 3
Obtain transthoracic echocardiogram to identify valvular disease, left atrial size, left ventricular function (LVEF), and structural abnormalities, as suggested by the European Heart Journal 4
Complete blood tests for thyroid, renal, and hepatic function to identify reversible causes, as recommended by the European Heart Journal 4
Calculate CHA₂DS₂-VASc score immediately: congestive heart failure (1 point), hypertension (1 point), age ≥75 years (2 points), diabetes (1 point), prior stroke/TIA (2 points), vascular disease (1 point), age 65-74 years (1 point), female sex (1 point), according to the European Heart Journal 4

The European Heart Journal recommends direct oral anticoagulants (DOACs) over warfarin in eligible patients due to lower risk of intracranial hemorrhage 4
Initiate oral anticoagulation for all patients with CHA₂DS₂-VASc score ≥2, as suggested by the European Heart Journal 4
Consider anticoagulation for score of 1, according to the European Heart Journal 4
DOAC options: apixaban 5 mg twice daily (or 2.5 mg twice daily if ≥2 of: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL), rivaroxaban, edoxaban, or dabigatran, as recommended by the European Heart Journal 4

For patients with preserved ejection fraction (LVEF >40%), use beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) as first-line therapy, as suggested by the European Heart Journal 4
Beta-blockers: metoprolol, atenolol, esmolol, according to the European Heart Journal 4
Diltiazem: 60-120 mg three times daily (or 120-360 mg extended release), as recommended by the European Heart Journal 4
Verapamil: 40-120 mg three times daily (or 120-480 mg extended release), according to the European Heart Journal 4

Rhythm control is appropriate for specific scenarios but has not been shown superior to rate control in reducing morbidity and mortality, as suggested by the Annals of Internal Medicine 1
Indications for rhythm control: hemodynamic instability requiring immediate electrical cardioversion, symptomatic patients despite adequate rate control, younger patients (<65 years) with new-onset AF, first episode in otherwise healthy patients, rate-related cardiomyopathy, patient preference after shared decision-making, according to the European Heart Journal 4

Selection must be based strictly on cardiac structure and LVEF—class I antiarrhythmics in structural heart disease can cause life-threatening proarrhythmia, as recommended by the European Heart Journal 4
No structural heart disease: flecainide, propafenone, or sotalol, according to the European Heart Journal 4
Coronary artery disease with LVEF >35%: sotalol first-line, as suggested by the European Heart Journal 4
Heart failure or LVEF ≤35%: amiodarone or dofetilide only safe options, according to the European Heart Journal 4

Consider as second-line option if antiarrhythmic drugs fail to control AF, as recommended by the European Heart Journal 4
Consider as first-line option in patients with paroxysmal AF, according to the European Heart Journal 4
Uninterrupted oral anticoagulation required during ablation procedure, as suggested by the European Heart Journal 4

In Wolff-Parkinson-White syndrome with pre-excited AF, NEVER use AV nodal blockers (adenosine, digoxin, diltiazem, verapamil, beta-blockers, amiodarone)—they can accelerate ventricular rate and precipitate ventricular fibrillation, as recommended by the European Heart Journal 4
Never withdraw anticoagulation based on successful rhythm control—stroke risk is determined by CHA₂DS₂-VASc score, not rhythm status, according to the European Heart Journal 4
Avoid pharmacological cardioversion in patients with sinus node dysfunction, AV conduction disturbances, or prolonged QTc (>500 ms) unless risks have been carefully considered, as suggested by the European Heart Journal 4
Do not cardiovert without adequate anticoagulation or TEE if AF duration >24 hours, according to the European Heart Journal 4