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Management of atrial fibrillation

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

AF management comprises of

  • therapies with prognostic impact - anticoagulation and treatment of cardiovascular conditions
  • therapies predominantly providing symptomatic benefit - rate control and rhythm control (1)

The main goals in the management of atrial fibrillation are:

  • urgent control of the ventricular rate during paroxysmal or persistent AF
  • restoration of sinus rhythm by pharmacologic or electrical means
  • prevention of thromboembolic complications
  • prevention of recurrence of AF following successful restoration of sinus rhythm
  • long-term rate control in those with permanent AF (2)

The therapeutic interventions may be considered under the following headings:

  • general measures
  • non-drug management
  • drug management

Indications for emergency rhythm control (4):

Patients with ongoing atrial fibrillation at the time of initial evaluation, as confirmed by 12 lead electrocardiography, and

  • with very slow or rapid ventricular rates (typically <40 bpm and >150 bpm),
  • evidence of hemodynamic instability,
  • severe symptoms,
  • or decompensated heart failure

  • should be referred to the emergency department for stabilization and possible electrical cardioversion
  • in case of unknown duration of atrial fibrillation
    • cardioversion should be preceded by transesophageal echocardiography to rule out intracardiac thrombus
    • patients are required to be on anticoagulation for at least four weeks after electrical cardioversion to reduce the risk of thromboembolism

NICE state (3) rhythm control should be favoured if:

  • atrial fibrillation has a reversible cause
  • heart failure thought to be primarily caused by atrial fibrillation
  • new-onset atrial fibrillation
  • atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
  • for whom a rhythm-control strategy would be more suitable based on clinical judgement

Ponamgi et al state rhythm control should be favored (4):

  • in the presence of significant atrial fibrillation related symptoms or presumed tachycardia induced cardiomyopathy
  • may also be preferable in younger (<65 years) patients with paroxysmal atrial fibrillation, as rate control alone is likely to result in progression to longstanding persistent atrial fibrillation over a period of time, which will later be more difficult to control and carries a risk of development of tachycardia induced cardiomyopathy


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