Atrial fibrillation management
Formal Definition
The structured approach to managing atrial fibrillation — the most common sustained cardiac arrhythmia characterized by disorganized atrial electrical activity leading to loss of atrial contraction, irregularly irregular ventricular response (usually 100-160 bpm without rate control), and increased thromboembolic risk; management focuses on three pillars: (1) rate control (beta-blocker, non-DHP CCB like diltiazem, digoxin), (2) rhythm control (antiarrhythmics, cardioversion, ablation), and (3) stroke prevention anticoagulation based on CHA2DS2-VASc score.
How It's Used on the Ward
"Afib" or "a-fib" — the heart's top chambers are quivering instead of contracting coherently, so the bottom chambers respond erratically and the patient feels irregular palpitations and is at risk for stroke because stagnant blood in the left atrial appendage can clot; the three management questions are: slow the rate, get them back to sinus (or not), and anticoagulate or not.
Example
""70-year-old woman presents with palpitations. EKG: irregularly irregular narrow-complex tachycardia at 138 bpm, no P waves, fibrillatory baseline. Diagnosis: atrial fibrillation with rapid ventricular response. Started IV metoprolol, transitioned to PO. TSH normal. TTE: LA enlargement 4.2cm, EF 55%, no structural disease. CHA2DS2-VASc score 4 (age 65-74, female, hypertension, diabetes). Started apixaban 5mg BID. Discussed rhythm vs rate control — patient prefers rate control strategy given recent diagnosis, age, no clear reversible trigger, and structural changes on echo.""
Clinical Context
Rate vs rhythm: AFFIRM and EAST-AFNET trials show similar mortality between strategies; rhythm control increasingly preferred for younger, symptomatic, new-onset, or heart failure patients (EAST-AFNET showed reduced CV death with early rhythm control). Rate control targets: <110 bpm at rest (lenient, AFFIRM trial) or <80 bpm at rest (strict) for symptomatic patients. Drugs: beta-blockers (metoprolol, carvedilol) first-line; non-DHP CCBs (diltiazem, verapamil) — avoid in HFrEF; digoxin for sedentary patients or as adjunct. Rhythm control: antiarrhythmics (flecainide for normal hearts, sotalol, amiodarone for heart failure); cardioversion (electrical or chemical) for hemodynamically unstable or symptomatic new-onset; ablation (pulmonary vein isolation) for symptomatic paroxysmal/persistent refractory to drugs. Anticoagulation: CHA2DS2-VASc — Congestive HF, Hypertension, Age ≥75 (2 points), Age 65-74, Diabetes, Stroke/TIA (2 points), Vascular disease, Sex (female). Score 0 (men) or 1 (women) → no anticoagulation. Score 1 (men) → consider. Score ≥2 → anticoagulate. DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) preferred over warfarin for non-valvular Afib. Valvular Afib (mechanical valve, moderate-severe MS) requires warfarin.