AF (Atrial Fibrillation)

Atrial Fibrillation (AF) – Treatment Options

Introduction
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, characterized by disorganized atrial electrical activity leading to an irregularly irregular ventricular rhythm. It is associated with increased risk of stroke, heart failure, hospitalization, and mortality. Management strategies aim to control symptoms, prevent thromboembolic events, and reduce cardiovascular complications. Treatment is individualized based on patient symptoms, comorbidities, AF type (paroxysmal, persistent, permanent), and thromboembolic risk.

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1. Rate Control

• Goal: Control ventricular response to allow adequate cardiac output.

• Beta-blockers (first-line): Metoprolol, atenolol, bisoprolol, propranolol.

• Non-dihydropyridine calcium channel blockers: Diltiazem, verapamil (avoid in heart failure with reduced ejection fraction).

• Digoxin: Useful in sedentary patients or those with heart failure; often combined with beta-blockers.

• Amiodarone: Considered when other agents are ineffective or contraindicated.

• Target heart rate: <110 bpm (lenient control) or <80 bpm (strict control) in symptomatic patients.

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2. Rhythm Control

• Goal: Restore and maintain sinus rhythm, especially in symptomatic or younger patients.

• Pharmacologic cardioversion:

  • Flecainide, propafenone (class IC; avoid in structural heart disease).

  • Amiodarone, dofetilide, sotalol (class III).

• Electrical cardioversion: Direct current shock; highly effective for persistent AF.

• Catheter ablation: Pulmonary vein isolation is effective in symptomatic patients refractory to drug therapy.

• Surgical options: Maze procedure (less common, usually during cardiac surgery).

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3. Stroke Prevention (Anticoagulation)

• Central to AF management, based on CHA₂DS₂-VASc score.

• Oral anticoagulants:

  • Direct oral anticoagulants (DOACs): Apixaban, rivaroxaban, edoxaban, dabigatran (preferred in most patients).

  • Warfarin: Used when DOACs are contraindicated (mechanical heart valves, severe mitral stenosis).

• Aspirin: Limited role; no longer recommended for stroke prevention in AF alone.

• Left atrial appendage occlusion (e.g., Watchman device): For patients with contraindications to long-term anticoagulation.

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4. Risk Factor Modification and Comorbidity Management

• Hypertension control: ACE inhibitors, ARBs, beta-blockers, calcium channel blockers.

• Management of diabetes, obesity, sleep apnea, and thyroid disease.

• Lifestyle measures: Weight reduction, alcohol moderation, smoking cessation, regular exercise.

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5. Management of Acute AF

• Hemodynamically unstable patients (hypotension, shock, heart failure, ischemia): Immediate synchronized electrical cardioversion.

• Stable patients: Rate control and anticoagulation; cardioversion considered depending on duration and risk of thromboembolism.