-
Acute AF w/ rapid ventricular response
Without acute medical illness/post noncardiac surgery Assess hemodynamic stability. If unstable, perform immediate synchronized cardioversion. If stable, consider electric cardioversion as initial strategy, or after failed pharmacologic cardioversion. If stable, rate control is reasonable strategy. Electrical cardioversion preferred if: - Pt able to tolerate sedation
- Desires immediate conversion
- Failed/not candidate for pharm conversion
If stable and pharm conversion preferred, multiple drug options: - ibutilide (≥60 kg: 1 mg over 10min; <60 kg: 0.01 mg/kg over 10min). If arrhythmia does not terminate w/in 10min after 1st infusion, may administer a 2nd dose. Rapid onset. AEs: nonsustained VT, QT prolongation, TdP. Avoid if LVEF ≤40%.
- amiodarone (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h). Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP. May use if LVEF ≤40%.
- procainamide (1 g IV over 30min, then 2 mg/min over 1h). Less effective than ibutilide. AEs: granulocytosis, AV block, HFrEF exacerbation, hypotension, neutropenia, QT prolongation, rash, thrombocytopenia, TdP. Avoid if initially treated w/ amiodarone or ibutilide. Consider only if ibutilide or amiodarone not optimal. Considered safe in pregnancy.
- IV sotalol not recommended.
If stable and rate control preferred, BBs or non-DHP CCBs (verapamil, diltiazem; if EF >40%) preferred meds. - Target rate guided by sx. Generally, goal HR <100-110.
- If known mod-severe LV dysfunction, w/ or w/o decompensated HF, avoid non-DHP CCBs.
- If BBs/CCBs ineffective or contraindicated, consider digoxin alone or in combo w/ BBs/CCBs.
- Consider adding IV Mg to achieve and maintain rate control.
- If critically ill or decompensated HF and BBs/CCBs infective/contraindicated, consider IV amiodarone.
- BB options:
◦ metoprolol 2.5- to 5-mg bolus over 2min, up to 3 doses
◦ esmolol 500-mcg/kg bolus over 1min, then 50-300 mcg/kg/min
◦ propranolol 1 mg over 1min, repeat q2min prn, up to 3 doses - Non-DHP CCB options (avoid in HFrEF):
◦ diltiazem 0.25 mg/kg over 2min. May repeat 0.35 mg/kg over 2min, then 5-15 mg/h continuous infusion.
◦ verapamil 5-10 mg over 2min. May repeat x2, then 5 mg/h continuous infusion (max 20 mg/h).
If refractory to rate-control meds and noncandidate/failed rhythm control, AVNA can improve sx and QOL but creates dependence on pacing. - Consider consequences of lifelong pacemaker implantation, esp. w/ respect to age and comorbidities in decision-making regarding benefit.
- No evidence supports AVNA as 1st-line tx.
- Implant pacemaker before or same day as ablation to ensure adequacy of pacing leads prior to ablation.
- Program initial pacemaker lower rate to 80-90 bpm to reduce risk of sudden death.
With acute medical illness/post noncardiac surgery If hemodynamically unstable due to AF, DC cardioversion. If stable, then rate and/or rhythm control. Treat underlying illness. Detect and treat potential triggers, optimize hemodynamics, assess risks/benefits of anticoagulation. Counsel about risks of recurrent AF. - Individualize rate vs. rhythm control to balance AF impact on hemodynamics vs. ability to tolerate tx.
- If AF in setting of sepsis, benefits of anticoagulation during critical illness uncertain.
- Base decisions about anticoagulation on risk stratification of pt and comorbidities. Consider timing, bleeding risks, and complexity of acute illness.
- Refer for outpt f/u for rhythm monitoring, lifestyle and risk factor modification, risk stratification for OAC initiation or continuation, need for continued rhythm/rate control.
If hemodynamically unstable or poorly tolerated sx, DC cardioversion. If stable, rate control w/ BB/non-DHP CCB (target HR <100) or rhythm control equal options. - If AF >48h, consider imaging to r/o thrombus before cardioversion.
- Amiodarone typically used for pharm cardioversion.
- Anticoagulate x60 days when deemed safe regarding surgical bleeding.
- If rate control strategy used, perform rhythm assessment at 30-60 days post-op. If persistent AF, consider anticoagulation and cardioversion.
-
Ongoing/acute AF, nonrapid ventricular response
Without HF, awaiting decision about rate- or rhythm-control approach In all pts, perform basic clinical eval, address modifiable risk factors (obesity, physical inactivity, EtOH consumption, smoking, DM, HTN), and assess stroke risk to determine need for anticoagulation ( CHA2DS2-VASc). Focus early on ongoing mgmt to maintain SR and minimize AF burden. Basic eval: - Assess sx and AF burden.1
- Confirm rhythm w/ 12-lead ECG.
- Echo, CBC, CMP, TSH
- In newly diagnosed AF, routine testing for ischemia, ACS, or PE not indicated unless s/sx suggest these diseases.
Risk factor modifications: - If BMI >27 kg/m^2, target 10% wt loss to reduce AF sx, burden, recurrence, and progression to persistent.
- Target 210min/wk of mod-vigorous exercise to reduce AF sx/burden, increase maintenance of SR, increase functional capacity, and improve QOL.
- Stop smoking to mitigate increased risk of AF-related CV complications and other adverse outcomes.
- Minimize or eliminate EtOH use to reduce AF recurrence and burden.
- Caffeine abstention has no benefit in preventing AF but may reduce sx in pts who report caffeine as trigger.
- Optimize BP control to reduce AF recurrence and AF-related CV events.
- Consider screening for OSA. Role of tx of sleep-disordered breathing to maintain SR is unclear.
Risk stratification for thrombosis risk and anticoagulation: - Use validated score (e.g., CHA2DS2-VASc). If male pt w/ CHA2DS2-VASc score of 1 or female pt w/ CHA2DS2-VASc score of 2 remains uncertain about the benefit of anticoagulation, consider other factors that might modify their stroke risk to help inform the decision (e.g., AF burden, BMI ≥30 kg/m^2, HCM, poorly controlled HTN, eGFR <45 mL/h, proteinuria >150 mg/24h, enlarged LA).
- Stroke risk is based on score and risk factors, not AF pattern.
- If congenital heart dz or HCM, anticoagulate regardless of stroke risk score.
- Re-evaluate annually.
- Evaluate for bleeding risks (prior bleeding, anemia, meds). Bleeding risk scores perform poorly. Do not use in isolation. ESC recommends HAS-BLED score.1
- Contraindications to long-term anticoagulation:
◦ Severe bleeding due to a nonreversible cause involving the GI, pulmonary, or GU systems
◦ Spontaneous intracranial/intraspinal bleeding due to a nonreversible cause
◦ Serious bleeding related to recurrent falls when cause of falls is not felt to be treatable
- Long-term anticoagulation reasonable if:
◦ Treatable GI, pulmonary, or GU system
◦ Bleeding related to isolated trauma
◦ Bleeding related to procedural complications
Considerations for rhythm vs. rate control: - If reduced LV function, trial of rhythm control recommended to evaluate if AF is contributing to reduced LV function.
- If symptomatic, rhythm control can improve sx. If uncertain about sx being due to AF, rhythm control trial may clarify.
- If AF dx <1y, rhythm control can reduce hospitalizations, stroke, and mortality.
- If HF, rhythm control reduces mortality and hospitalizations for HF and ischemia.
- Rhythm control can reduce likelihood of AF progression.
- If adult w/ congenital heart dz, rhythm control preferred.
- If hx of pulm HTN, rhythm control preferred.
- Rhythm control may reduce development of dementia or worsening cardiac structural abnormalities.
- Rate control favored if:
◦ Pt preference
◦ Older age
◦ Longer AF hx
◦ Fewer sx
◦ Easily controlled HR
◦ Larger LA
◦ Less LV dysfunction
◦ Less AV regurgitation
◦ No or minor sx1
◦ Risks of restoring SR > benefits1
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
Without HF, rate-control approach desired No anti-coag risk factors Long-term rate control w/ BBs or non-DHP CCBs as 1st line. - If BBs/CCBs contraindicated, not tolerated, or not preferred, digoxin is option. Target digoxin level <1.2 ng/mL. May be used in combo w/ BBs/CCBs.
- Avoid dronedarone in pts w/ CV risk factors.
- If pregnant, BB or digoxin 1st line for rate control.
- Target HR based on sx. Aim for <100-110 bpm.1
- If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- If stroke risk 1% to 2% per year (CHA2DS2-VASc = 1 in men, 2 in women), anticoagulation is reasonable.
- If stroke risk ≥2% per year (CHA2DS2-VASc ≥2 in men, ≥3 in women), anticoagulate.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. Warfarin safe in all trimesters. If warfarin dose >5 mg/day, use LMWH. Stop anticoagulation 36h before planned delivery.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
Long-term rate control w/ BBs or non-DHP CCBs as 1st line. - If BBs/CCBs contraindicated, not tolerated, or not preferred, digoxin is option. Target digoxin level <1.2 ng/mL. May be used in combo w/ BBs/CCBs.
- Avoid dronedarone in pts w/ CV risk factors.
- If pregnant, BB or digoxin 1st line for rate control.
- Target HR based on sx. Aim for <100-110 bpm.1
If CHA2DS2-VASc ≥2 w/ contraindications to oral anticoagulation or high risk of major bleeding, percutaneous LAAO is reasonable option. - Benefit of surgical LAA exclusion in absence of anticoagulation and risk of stroke/systemic embolism is uncertain.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
Without HF, rhythm-control approach desired No anti-coag risk factors Either electrical or pharmacological cardioversion is acceptable, safe, and effective. Electrical cardioversion is more effective but involves risk of anesthesia/sedation. Thromboembolic risks and considerations for anticoagulation still apply. - If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- If stroke risk 1% to 2% per year (CHA2DS2-VASc = 1 in men, 2 in women), anticoagulation is reasonable.
- If stroke risk ≥2% per year (CHA2DS2-VASc ≥2 in men, ≥3 in women), anticoagulate.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. Warfarin safe in all trimesters. If warfarin dose >5 mg/day, use LMWH. Stop anticoagulation 36h before planned delivery.
Prevention of thromboembolism in setting of cardioversion - If AF duration ≥48h, then anticoagulation x3wk or imaging to exclude cardiac thrombus.
- Begin anticoagulation prior to cardioversion and continue x4wk.
- If imaging shows LAA thrombus, anticoagulate x3-6wk, then repeat imaging prior to cardioversion.
- If prior LAAO w/o anticoagulation, image to exclude device-related thrombus prior to cardioversion.
- If AF duration <48h and CHA2DS2-VASc score ≥2, consider precardioversion imaging to exclude thrombus.
- If AF duration <12h w/ CHA2DS2-VASc score 0-1, benefit of precardioversion imaging is uncertain.
Considerations for DC cardioversion: - Preferred if pt can tolerate sedation, desires rapid conversion, or if not candidate/failed pharm conversion. Safe in pregnancy.
- Consider pre-tx w/ amiodarone, flecainide, ibutilide, or propafenone to facilitate success.1
- Use synchronized cardioversion to prevent VT.
- Use biphasic 200 J initial energy to improve success of initial shock.
- If initial shock unsuccessful or longer-duration AF, consider anterior-post electrode vector orientation, higher energy, pre-tx w/ antiarrhythmic drugs.
- If pt has obesity, manual pressure augmentation or escalation of energy may improve success.
If hemodynamically stable or DC can’t be performed, use pharmacologic cardioversion. Multiple medication options: - ibutilide (≥60 kg: 1 mg over 10min; <60 kg: 0.01 mg/kg over 10min). If arrhythmia does not terminate w/in 10min after 1st infusion, may administer a 2nd dose. Rapid onset. AEs: nonsustained VT, QT prolongation, TdP. Avoid if LVEF ≤40%.
- amiodarone (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h). Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP. May use if LVEF ≤40%.
- procainamide (1 g IV over 30min, then 2 mg/min over 1h). Less effective than ibutilide. AEs: granulocytosis, AV block, HFrEF exacerbation, hypotension, neutropenia, QT prolongation, rash, thrombocytopenia, TdP. Avoid if initially treated w/ amiodarone or ibutilide. Consider only if ibutilide or amiodarone not optimal. Considered safe in pregnancy.
- IV sotalol not recommended.
- Avoid pharm conversion if sick-sinus syndrome, AV conduction disturbances, QTc >500 ms.1
- “Pill in the pocket” strategy reasonable for select pts:
◦ Test 1st as inpt trial w/ monitoring.
◦ Give BB/non-DHP CCB PO 30min prior to single PO dose of flecainide or propafenone.
Once converted, consider catheter ablation in appropriate pts. Ablation is more effective than antiarrhythmic drugs for persistent and paroxysmal AF. - Earlier implementation of rhythm control improves ablation success.
- Useful if antiarrhythmic meds ineffective/contraindicated/not tolerated and in those w/ symptomatic/clinically significant AFL. ESC recommends ablation after 1 failed/not-tolerated BB tx.1
- 1st-line tx for paroxysmal AF in younger pts w/ few comorbidities, to reduce progression to persistent AF. Consider in others. First line for paroxysmal AF or persistent AF w/o major risk factors for recurrence.1
- If athlete, consider ablation.
- Complications include LA-esophageal fistula, perforation w/ tamponade, CVA/TIA, PV stenosis, phrenic nerve paralysis, vasc access complications, death, pneumonia.
- Post ablation, continue anticoagulation x3mo, longer if CHA2DS2-VASc ≥2.
- If recurrent AF post ablation, repeat ablation or initiate pharm options for rate or rhythm control.
If not candidate for ablation, prescribe meds for long-term maintenance of SR. Consider medical hx and drug-drug interactions for choice. Options include: - If no prior MI or structural heart dz, flecainide or propafenone; if no HFrEF, dronedarone. Low-dose amiodarone 2nd line.
- If using flecainide, consider combo w/ BB/non-DHP CCB.1
- If no prolonged QT, hypokalemia, hypomagnesemia, dofetilide is 1st-line option w/ close monitor of QT, K+, Mg, and kidney function. Initiate as inpt for 3-day monitoring.
- Sotalol 3rd-line option if no bradycardia. Initiate as inpt for 3-day monitoring.
- If pregnant, flecainide and sotalol reasonable options.
- If prior MI/structural heart dz, amiodarone, dofetilide 1st line. Sotalol 2nd line. Flecainide and propafenone contraindicated.
- Ongoing monitoring required:
◦ amiodarone: TSH, AST, ALT (q3-6mo), ECG (q1y), CXR and physical exam for visual abnormalities, skin changes, neuro sx annually.
◦ dofetilide: ECG, K+, Mg, CrCl q3-6mo.
◦ dronedarone: ECG, AST, ALT w/in first 6mo.
◦ procainamide: ECG, BP.
◦ sotalol: ECG, K+, Mg, CrCl q3-6mo.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
Either electrical or pharmacological cardioversion is acceptable, safe, and effective. Electrical cardioversion is more effective but involves risk of anesthesia/sedation. If CHA2DS2-VASc ≥2 w/ contraindications to oral anticoagulation or high risk of major bleeding, percutaneous LAAO is reasonable option. - Benefit of surgical LAA exclusion in absence of anticoagulation and risk of stroke/systemic embolism is uncertain.
Prevention of thromboembolism in setting of cardioversion - If AF duration ≥48h, image to exclude cardiac thrombus.
- If prior LAAO w/o anticoagulation, image to exclude device-related thrombus prior to cardioversion.
- If AF duration <48h and CHA2DS2-VASc score ≥2, consider precardioversion imaging to exclude thrombus.
- If AF duration <12h w/ CHA2DS2-VASc score 0-1, benefit of precardioversion imaging is uncertain.
Considerations for electric cardioversion: - Preferred if pt can tolerate sedation, desires rapid conversion, or if not candidate/failed pharm conversion. Safe in pregnancy.
- Consider pre-tx w/ amiodarone, flecainide, ibutilide, or propafenone to facilitate success.1
- Use synchronized cardioversion to prevent VT.
- Use biphasic 200 J initial energy to improve success of initial shock.
- If initial shock unsuccessful or longer-duration AF, consider anterior-post electrode vector orientation, higher energy, pre-tx w/ antiarrhythmic drugs.
- If pt has obesity, manual pressure augmentation or escalation of energy may improve success.
If hemodynamically stable or electric can’t be performed, use pharmacologic cardioversion. Multiple medication options: - ibutilide (≥60 kg: 1 mg over 10min; <60 kg: 0.01 mg/kg over 10min). If arrhythmia does not terminate w/in 10min after 1st infusion, may administer a 2nd dose. Rapid onset. AEs: nonsustained VT, QT prolongation, TdP. Avoid if LVEF ≤40%.
- amiodarone (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h). Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP. May use if LVEF ≤40%.
- procainamide (1 g IV over 30min, then 2 mg/min over 1h). Less effective than ibutilide. AEs: granulocytosis, AV block, HFrEF exacerbation, hypotension, neutropenia, QT prolongation, rash, thrombocytopenia, TdP. Avoid if initially treated w/ amiodarone or ibutilide. Consider only if ibutilide or amiodarone not optimal. Considered safe in pregnancy.
- IV sotalol not recommended.
- Avoid pharm conversion if sick-sinus syndrome, AV conduction disturbances, QTc >500 ms.1
- “Pill in the pocket” strategy reasonable for select pts:
◦ Test 1st as inpt trial w/ monitoring.
◦ Give BB/non-DHP CCB PO 30min prior to single PO dose of flecainide or propafenone.
Once converted, consider catheter ablation in appropriate pts. Ablation is more effective than antiarrhythmic drugs for persistent and paroxysmal AF. - Earlier implementation of rhythm control improves ablation success.
- Useful if antiarrhythmic meds ineffective/contraindicated/not tolerated and in those w/ symptomatic/clinically significant AFL. ESC recommends ablation after 1 failed/not-tolerated BB tx.1
- 1st-line tx for paroxysmal AF in younger pts w/ few comorbidities, to reduce progression to persistent AF. Consider in others. First line for paroxysmal AF or persistent AF w/o major risk factors for recurrence.1
- If athlete, consider ablation.
- Complications include LA-esophageal fistula, perforation w/ tamponade, CVA/TIA, PV stenosis, phrenic nerve paralysis, vasc access complications, death, pneumonia.
- If recurrent AF post ablation, repeat ablation or initiate pharm options for rate or rhythm control.
If not candidate for ablation, prescribe meds for long-term maintenance of SR. Consider medical hx and drug-drug interactions for choice. Options include: - If no prior MI or structural heart dz, flecainide or propafenone; if no HFrEF, dronedarone. Low-dose amiodarone 2nd line.
- If using flecainide, consider combo w/ BB/non-DHP CCB.1
- If no prolonged QT, hypokalemia, hypomagnesemia, dofetilide is 1st-line option w/ close monitor of QT, K+, Mg, and kidney function. Initiate as inpt for 3-day monitoring.
- Sotalol 3rd-line option if no bradycardia. Initiate as inpt for 3-day monitoring.
- If pregnant, flecainide and sotalol reasonable options.
- If prior MI/structural heart dz, amiodarone, dofetilide 1st line. Sotalol 2nd line. Flecainide and propafenone contraindicated.
- Ongoing monitoring required:
◦ amiodarone: TSH, AST, ALT (q3-6mo), ECG (q1y), CXR and physical exam for visual abnormalities, skin changes, neuro sx annually.
◦ dofetilide: ECG, K+, Mg, CrCl q3-6mo.
◦ dronedarone: ECG, AST, ALT w/in first 6mo.
◦ procainamide: ECG, BP.
◦ sotalol: ECG, K+, Mg, CrCl q3-6mo.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
With HF, awaiting decision about rate- or rhythm-control approach Provide guideline-directed medical tx for HF. In all pts, perform basic clinical eval, address modifiable risk factors (obesity, physical inactivity, EtOH consumption, smoking, DM, HTN), and assess stroke risk to determine need for anticoagulation ( CHA2DS2-VASc). If new dx of HFrEF and AF, suspect arrhythmia-induced cardiomyopathy and take early and aggressive approach to rhythm control. Ablation for rhythm control 1st-line tx in many. Basic eval: - Confirm rhythm w/ 12-lead ECG.
- Echo, CBC, CMP, TSH
- In newly diagnosed AF, routine testing for ischemia, ACS, or PE not indicated unless s/sx suggest these diseases.
Risk factor modifications: - If BMI >27 kg/m^2, target 10% wt loss to reduce AF sx, burden, recurrence, and progression to persistent.
- Target 210min/wk of mod-vigorous exercise to reduce AF sx/burden, increase maintenance of SR, increase functional capacity, and improve QOL.
- Stop smoking to mitigate increased risk of AF-related CV complications and other adverse outcomes.
- Minimize or eliminate EtOH use to reduce AF recurrence and burden.
- Caffeine abstention has no benefit in preventing AF but may reduce sx in pts who report caffeine as trigger.
- Optimize BP control to reduce AF recurrence and AF-related CV events.
- Consider screening for OSA. Role of tx of sleep-disordered breathing to maintain SR is unclear.
Risk stratification for thrombosis risk and anticoagulation: - Use validated score (e.g., CHA2DS2-VASc). If male pt w/ CHA2DS2-VASc score of 1 or female pt w/ CHA2DS2-VASc score of 2 remains uncertain about the benefit of anticoagulation, consider other factors that might modify their stroke risk to help inform the decision (e.g., AF burden, BMI ≥30 kg/m^2, HCM, poorly controlled HTN, eGFR <45 mL/h, proteinuria >150 mg/24h, enlarged LA).
- Stroke risk is based on score and risk factors, not AF pattern.
- If congenital heart dz or HCM, anticoagulate regardless of stroke risk score.
- Re-evaluate annually.
- Evaluate for bleeding risks (prior bleeding, anemia, meds). Bleeding risk scores perform poorly. Do not use in isolation. ESC recommends HAS-BLED score.1
- Contraindications to long-term anticoagulation:
◦ Severe bleeding due to a nonreversible cause involving the GI, pulmonary, or GU systems
◦ Spontaneous intracranial/intraspinal bleeding due to a nonreversible cause
◦ Serious bleeding related to recurrent falls when cause of falls is not felt to be treatable - Long-term anticoagulation reasonable if:
◦ Treatable GI, pulmonary, or GU system
◦ Bleeding related to isolated trauma
◦ Bleeding related to procedural complications
Considerations for rhythm vs. rate control: - If reduced LV function, trial of rhythm control recommended to evaluate if AF is contributing to reduced LV function.
- If HFrEF, routine pharm rhythm control no benefit vs. rate control.
- If HFrEF, consider catheter ablation to improve sx, QOL, and CV outcomes and reduce mortality and HF hospitalizations.
- If HFpEF, ablation also an option.
Catheter ablation considerations: - Those likely to benefit: earlier stage of HF, no significant ventricular scar on CMR, no/mild atrial fibrosis, paroxysmal and early persist AF, younger pts w/o comorbidities.
- Less likely to benefit: advanced HF, AF-mediated cardiomyopathies suspected, significant ventricular scar on CMR, severe atrial myopathy/dilation/fibrosis, long-standing persistent AF, prior failed ablations, advanced age or multiple comorbidities.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
With HF, rate control preferred Assess EF. If EF ≤40%, avoid non-DHP CCBs. Long-term rate control w/ BB is 1st line. - If EF >40%, BBs or non-DHP CCBs are 1st line.
- If BBs contraindicated, not tolerated, or not preferred, digoxin is option. Target digoxin level <1.2 ng/mL. May be used in combo w/ BBs/CCBs.
- IV amiodarone is 3rd line for acute rate control.
- If refractory HF sx on rate-control tx, consider target HR <80 bpm at rest and <110 bpm during mod exercise.
- Evaluate for catheter ablation.
- If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- If stroke risk 1% to 2% per year (CHA2DS2-VASc = 1 in men, 2 in women), anticoagulation is reasonable.
- If stroke risk ≥2% per year (CHA2DS2-VASc ≥2 in men, ≥3 in women), anticoagulate.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. Warfarin safe in all trimesters. If warfarin dose >5 mg/day, use LMWH. Stop anticoagulation 36h before planned delivery.
With HF, rhythm control preferred Assess EF. Either DC or pharmacological cardioversion is acceptable, safe, and effective. DC cardioversion is more effective but involves risk of anesthesia/sedation. Thromboembolic risks and considerations for anticoagulation still apply. Consider catheter ablation. - If stroke risk <1% per year, no anticoagulation. Aspirin not recommended.
- If stroke risk 1% to 2% per year (CHA2DS2-VASc = 1 in men, 2 in women), anticoagulation is reasonable.
- If stroke risk ≥2% per year (CHA2DS2-VASc ≥2 in men, ≥3 in women), anticoagulate.
- Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. Warfarin safe in all trimesters. If warfarin dose >5 mg/day, use LMWH. Stop anticoagulation 36h before planned delivery.
Prevention of thromboembolism in setting of cardioversion - If AF duration ≥48h, then anticoagulation x3wk or imaging to exclude cardiac thrombus.
- Begin anticoagulation prior to cardioversion and continue x4wk.
- If imaging shows LAA thrombus, anticoagulate x3-6wk, then repeat imaging prior to cardioversion.
- If prior LAAO w/o anticoagulation, image to exclude device-related thrombus prior to cardioversion.
- If AF duration <48h and CHA2DS2-VASc score ≥2, consider precardioversion imaging to exclude thrombus.
- If AF duration <12h w/ CHA2DS2-VASc score 0-1, benefit of precardioversion imaging is uncertain.
Considerations for DC cardioversion: - Preferred if pt can tolerate sedation, desires rapid conversion, or if not candidate/failed pharm conversion. Safe in pregnancy.
- Consider pre-tx w/ amiodarone, flecainide, ibutilide, or propafenone to facilitate success.1
- Use synchronized cardioversion to prevent VT.
- Use biphasic 200 J initial energy to improve success of initial shock.
- If initial shock unsuccessful or longer-duration AF, consider anterior-post electrode vector orientation, higher energy, pre-tx w/ antiarrhythmic drugs.
- If pt has obesity, manual pressure augmentation or escalation of energy may improve success.
If hemodynamically stable or electric can’t be performed, use pharmacologic cardioversion. Multiple medication options: - Amiodarone 1st line if EF ≤40% (5-7 mg/kg or 300 mg, then 1200-3000 mg IV over 24h). Slow onset (8-12h). AEs: bradycardia, hypotension, QT prolongation, phlebitis, TdP.
- Avoid ibutilide, dronedarone.
- IV sotalol not recommended.
Once converted, consider catheter ablation in appropriate pts. Ablation is more effective than antiarrhythmic drugs for persistent and paroxysmal AF. - Earlier implementation of rhythm control improves ablation success.
- Useful if antiarrhythmic meds ineffective/contraindicated/not tolerated and in those w/ symptomatic/clinically significant AFL. ESC recommends ablation after 1 failed/not-tolerated BB tx.1
- 1st-line tx for paroxysmal AF in younger pts w/ few comorbidities, to reduce progression to persistent AF. Consider in others. First line for paroxysmal AF or persistent AF w/o major risk factors for recurrence.1
- Complications include LA-esophageal fistula, perforation w/ tamponade, CVA/TIA, PV stenosis, phrenic nerve paralysis, vasc access complications, death, pneumonia.
- Post ablation, continue anticoagulation x3mo, longer if CHA2DS2-VASc ≥2.
- If recurrent AF post ablation, repeat ablation or initiate pharm options for rate or rhythm control.
If not candidate for ablation, prescribe meds for long-term maintenance of SR. Consider medical hx and drug-drug interactions for choice. Options include: - If EF <40%, amiodarone or dofetilide is 1st line.
- If no prolonged QT, hypokalemia, hypomagnesemia, dofetilide is 1st-line option w/ close monitor of QT, K+, Mg, and kidney function. Initiate as inpt for 3-day monitoring.
- Sotalol 2nd-line option if no bradycardia. Initiate as inpt for 3-day monitoring.
- Flecainide and propafenone contraindicated.
- Ongoing monitoring required:
◦ amiodarone: TSH, AST, ALT (q3-6mo), ECG (q1y), CXR and physical exam for visual abnormalities, skin changes, neuro sx annually.
◦ dofetilide: ECG, K+, Mg, CrCl q3-6mo.
◦ sotalol: ECG, K+, Mg, CrCl q3-6mo.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
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Device-detected AF/Silent AF
AF may be detected w/ reliable monitoring device (wearable continuous or loop-recording devices, implantable loop recorders, pacemakers/defibrillators) and confirmed by physician review. Smartphones/smartwatches can discriminate AF vs. NSR but are not reliable enough to establish AF dx. Monitoring for AF may be appropriate in pts w/ cryptogenic stroke. - If monitoring device shows AF, perform 12-lead ECG.1
- If no AF on 12-lead, diagnose subclinical AF. If AF on 12-lead, treat as clinical AF.1
- Treat modifiable stroke risk factors.1
- Provide ongoing monitoring for progression to clinical AF and change in stroke risk.
Decision to anticoagulate is based on length of AF episodes and stroke risk. Device-detected AF is assoc. w/ lower stroke risk than clinical AF. Confirm duration and nature of longest device-detected episode. Assess stroke risk (e.g., CHA2DS2-VASc). - If AF lasts ≥24h w/ CHA2DS2-VASc ≥2 in men, ≥3 in women, reasonable to anticoagulate w/ shared decision-making and based on individual pt risk.
- If AF lasts 5min to 24h w/ CHA2DS2-VASc ≥3, reasonable to anticoagulate w/ shared decision-making and based on individual pt risk.
- If AF episode lasts <5min, no increased stroke risk. Do not anticoagulate.
If anticoagulation is appropriate, DOACs preferred. - Aspirin alone or w/ clopidogrel not recommended as alternative to anticoagulation.
- If mitral stenosis or mech heart valve, warfarin 1st line. DOACs 1st line for other valve dz.
- If post bariatric surgery, warfarin 1st line due to concerns about DOAC absorption.
- If hx/active CA, DOACs 1st line.
- Consider drug interactions when prescribing warfarin and DOACs, esp. CYP3A4 and/or p-glycoprotein inhibitors or inducers. May require altered dosing.
- DOAC options
◦ Direct thrombin inhibitor: dabigatran
◦ Factor Xa inhibitors: rivaroxaban; apixaban; edoxaban
◦ If liver dz (Child-Pugh Class B): Avoid rivaroxaban. - If using warfarin, target INR = 2-3, consistent vit K dietary intake and routine INR monitoring.
- If ACS or PCI, DOAC + antiplatelet preferred over warfarin. If PCI, d/c aspirin early (1-4wk) and continue DOAC + P2Y12 inhibitor vs. triple tx to reduce bleed risk.
- If ≥1y post PCI or CAD w/o coronary revasc, OAC monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If PAD, anticoagulant monotherapy preferred over combo tx w/ aspirin/P2Y12 inhibitors.
- If stage 3 or 4 CKD w/ elevated stroke risk, prescribe warfarin, or DOAC dose adjusted for CrCl.
- If ESRD (CrCl <15 mL/min) or dialysis w/ elevated stroke risk, prescribe warfarin or appropriate-dose apixaban.
- If pregnant, DOACs not recommended. Warfarin safe in all trimesters. If warfarin dose >5 mg/day, use LMWH. Stop anticoagulation 36h before planned delivery.
Footnotes 1 Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. Free, full-text PDF
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