Treatment

• Unstable patients: emergent electrical cardioversion (see “Management of unstable tachycardia with a pulse”)

• Stable patients: The goal is to control heart rate and/or rhythm.

  • Acute management: See “Management of atrial fibrillation with RVR.”

  • Long-term management:

    • The choice of rate control versus rhythm control depends on institutional preferences and individual patient risk factors.

• All patients

  • Correct reversible causes and/or treatable conditions, e.g., hyperthyroidism, electrolyte imbalances

  • Prevention of thromboembolic complications: Consider indications for anticoagulation

  • Encourage lifestyle modifications that reduce the risk of recurrence and decrease the likelihood of complications, e.g., weight loss, exercise, and reducing alcohol consumption.

Patients with unstable Afib should be treated with immediate electrical cardioversion!

• The goal is to normalize the ventricular heart rate to reduce symptoms.

• Target resting heart rate

  • < 110/minute: for patients who remain asymptomatic or have normal LV systolic function

  • < 80/minute: for patients who continue to be symptomatic with a lenient rate

• Consider rate control strategy especially in elderly patients

• Contraindications: Afib due to preexcitation syndromes

• First-line

  • Beta blockers (e.g., metoprolol, atenolol, propranolol)

    • Preferred when Afib is due to hyperthyroidism and in pregnant patients

    • Avoid in patients with COPD.

  • Nondihydropyridine calcium channel blockers (e.g., diltiazem, verapamil)

    • Avoid in patients with decompensated heart failure (LV systolic dysfunction/low ejection fraction).

    • Can be safely used in heart failure with preserved normal LV systolic function.

• Second line: digoxin; preferred as first-line therapy in patients with decompensated HF when beta blockers are contraindicated.

• Third line: amiodarone; typically reserved for patients in whom all other options have failed

• AV nodal ablation and implantation of a permanent ventricular pacemaker

  • Irreversible procedure

  • Eliminates the need for rate-controlling medications but leads to lifelong dependence on a pacemaker.

  • Indications

    • Recurrent Afib

    • Afib refractory to medical rate control

    • Patients who do not tolerate the pharmacological options for Afib management

• Goal: termination of atrial fibrillation (or flutter) and restoration of sinus rhythm in order to prevent atrial remodeling and improve symptoms

• Consider rhythm control in the following patient groups:

  • Failure of rate control strategy to control symptoms or achieve target heart rate

  • New-onset Afib

  • Acute illness that precipitated Afib

  • Other: tachycardia-induced cardiomyopathy, pregnancy, patient preference, younger patients

• Options include electrical cardioversion, pharmacological cardioversion, interventional cardioversion

• Contraindications (for any form of cardioversion): [17]

  • Long-standing persistent Afib for which cardioversion is unlikely to be successful [5]

  • Reversible causes, e.g., digoxin toxicity or electrolyte imbalances

  • High-risk of thromboembolic events, e.g., known atrial thrombus, suboptimal anticoagulation

• Initiate anticoagulation before cardioversion to reduce the risk of stroke (see “Anticoagulation during cardioversion in atrial fibrillation”).

• Consider indications for TEE prior to cardioversion (see “Transesophageal echocardiogram for atrial fibrillation”)

• Gradually increasing strengths of direct current shock (synchronized with the R wave) are administered under procedural sedation until sinus rhythm is restored.

• Can be performed in an emergency in unstable patients or electively in stable patients

• The use of antiarrhythmic drugs prior to planned cardioversion may increase the likelihood of successful electrical cardioversion.

• More effective for atrial flutter when compared with Afib but there is a risk of conversion to 1:1 conduction with propafenone and flecainide

• Inpatient regimens using intravenous or oral antiarrhythmics:

  • Dofetilide

  • Ibutilide

  • Flecainide

  • Propafenone

  • Amiodarone

• Pill-in-pocket approach

  • A single, self-administered dose of an anti-arrhythmic (e.g., flecainide, propafenone) used outside of the hospital to terminate atrial fibrillation

  • Typically given in conjunction with a beta blocker or ndHP CCB

  • May be used in patients with recent onset of Afib with infrequent episodes and no history of structural or ischemic heart disease

  • Patients should be monitored on the regimen in the hospital environment before they can self-administer.

• Description: Creation of scar tissue that prevents the spread of ectopic impulses.

  • Catheter radiofrequency ablation of atrial tissue around pulmonary vein openings (pulmonary vein isolation)

  • Maze ablation: a series of incisions are made in the atrial endocardium either via a catheter or surgically to prevent atrial macroentry.

• Indications: patients undergoing cardiac surgery for other reasons, symptomatic refractory Afib, patient preference, concurrent CHF with reduced LVEF

Both techniques increase the risk of thromboembolic events; patients must be candidates for anticoagulation to be considered for these procedures.

Anticoagulation therapy should be considered in all patients undergoing cardioversion.

• Hemodynamically unstable patients: anticoagulate as soon as possible, but this should not delay electrical cardioversion.

• Valvular Afib: anticoagulation prior to the procedure and this should be continued long-term after the procedure

• Nonvalvular Afib: risk-stratify patients using the CHA2DS2-VASc score to determine the need for anticoagulation before and after cardioversion.

• Overview

  • Can be used prior to cardioversion to evaluate for thrombus and reduce the risk of thromboembolic events

  • TEE visualizes the atria and the left atrial appendage (hotspots for thrombogenesis)

• Indications (prior to cardioversion) [33]

  • New-onset atrial fibrillation or atrial flutter for > 48 hours or for an unknown duration

  • No previous anticoagulant use or subtherapeutic anticoagulation

  • CHF exacerbation or hemodynamic instability

  • Symptomatic Afib (e.g., palpitations, chest pain, dyspnea, syncope, fatigue, lightheadedness)

  • High stroke risk (e.g., history of stroke, left atrial thrombus, HOCM, or rheumatic fever)

• Interpretation

  • No thrombus identified: 3 weeks of preceding anticoagulation is not required.

  • Thrombus identified: Patients should ideally receive ≥ 3 weeks of anticoagulation and a repeat TEE prior to any procedure.