AGS

Management Considerations

  • Patients presenting with acute AF complicated by hypotension, severe angina, or advanced HF should be considered for urgent direct-current cardioversion.
  • For acute management of AF with rapid ventricular response in patients who do not receive or respond to cardioversion, ventricular rate should be acutely lowered with one or more of the following medications:
    • β-Blockers, eg, metoprolol* 2.5–5 mg IV bolus over 2 min; may repeat twice
    • Diltiazem*, 0.25 mg/kg IV over 2 min
    • Verapamil*, 0.075–0.15 mg/kg IV over 2 min
  • For patients with minimal symptoms, or in whom sinus rhythm cannot be easily maintained, an appropriate treatment strategy is rate control (target resting heart rate <110 bpm in asymptomatic patients with normal left ventricular ejection fraction [EF]; <80 bpm in symptomatic patients or with reduced EF) plus antithrombotic therapy.
    • In patients with normal left ventricular systolic function (EF≥50%), rate control can be achieved with an oral β-blocker, diltiazem, or verapamil.
    • In patients with left ventricular systolic dysfunction (EF<50%), first-line treatment for rate control is a β-blocker approved for use in patients with heart failure (metoprolol succinate, carvedilol, bisoprolol), titrated to target dose as tolerated. Low dose digoxin (trough digoxin level <1.2 ng/ml) can be added if the heart rate remains elevated despite maximally tolerated doses of a β-blocker. Amiodarone (see Selected Medication for Rhythm Control in AF) can be used as an alternative for rate control, but should not be considered first-line therapy because amiodarone has been associated with increased mortality in some studies of patients with AF.
    • In patients with pre-excitation and AF, digoxin, diltiazem, verapamil, and amiodarone are contraindicated.
    • For symptomatic patients in whom ventricular rate does not respond to pharmacologic therapy after repeated attempts, atrioventricular node ablation with pacemaker placement can effectively control rate but does not obviate the need for antithrombotic therapy. In addition, with conventional right ventricular pacing some patients may develop symptoms related to pacemaker-induced left bundle branch block morphology (pacemaker syndrome).
    • Antithrombotic therapy (see Selected Risk Instrument to Guide Antithrombotic Treatment in AF) should be individualized to balance reduced stroke risk vs increased bleeding risk. The CHA2DS2–VASc scoring instrument is used for assessing stroke risk while bleeding risk can be assessed using the HAS–BLED score.
    • Direct-acting oral anticoagulants (DOACs: apixaban, dabigatran, edoxaban, rivaroxaban) are preferred over warfarin as first-line agents in nonvalvular AF due to lower rates of all-cause mortality, hemorrhagic stroke, and major bleeding. However, DOACs are not recommended in patients with mechanical heart valves or rheumatic mitral stenosis of moderate or greater severity.
    • Apixaban is associated with lower rates of major bleeding and stroke or embolism when compared to rivaroxaban. Dabigatran and rivaroxaban have higher rates of non–major GI bleeding compared to warfarin.
    • Warfarin is an alternative agent to DOACs in cases of patient preference or cost. It is the first-line agent in patients with mechanical heart valves or rheumatic mitral stenosis of moderate or greater severity.
    • Antithrombotic therapy dosing: 
      • Dabigatran (Pradaxa): 150 mg po q12h [T: 75, 150]; reduce dosage to 75 mg po q12h if CrCl 15–30 mL/min.
      • Rivaroxaban (Xarelto): 20 mg/d po taken with evening meal [T: 10, 15, 20] when CrCl is >50 mL/min; 15 mg/d po taken in evening when CrCl is 15–50 mL/min.
      • Apixaban (Eliquis): 5 mg po q12h [T: 2.5, 5]; Lower dose to 2.5 mg po q12h if patient has two of the following: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL.
      • Edoxaban (Savaysa): 60 mg po qd if eGFR >50–95 ml/min, 30 mg po qd if eGFR 15–50 ml/min; contraindicated if eGFR <15 or >95 ml/min [T 30, 60].
      • Warfarin (Coumadin): titrate to achieve INR 2–3 [T: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10].
    • Antithrombotic therapy reversal:
      • Warfarin:
        INR 5-10, no bleeding: consider oral vitamin K 1.0-2.5 mg
        INR>10, no bleeding: oral vitamin K 2.5-5.0 mg
        Active bleeding: vitamin K 10 mg IV over 30 minutes + fresh frozen plasma OR prothrombin complex concentrate
      • Dabigatran: Idarucizimab 2.5 mg IV x 2 within 15 minutes of each other; additional doses may be needed
      • Apixaban and rivaroxaban: Andexanet alfa – see package insert for dosing OR prothrombin complex concentrate
      • Edoxaban: prothrombin complex concentrate
  • For patients with bothersome symptoms or decreased exercise tolerance on rate control therapy, rhythm control via direct-current or pharmacologic cardioversion is the preferred treatment strategy.
    • For direct-current cardioversion, three approaches may be used:
      • Early cardioversion (<12-24 h from onset): proceed with cardioversion; use adjunctive anticoagulation based on risk of thromboembolism (e.g. CHA2DS2–VASc score).
      • Delayed cardioversion (≥24 h from onset) with transesophageal echocardiography (TEE): begin anticoagulation and perform TEE to exclude intracardiac thrombus; if no thrombus, cardiovert and continue anticoagulation for at least 4 weeks.
      • Delayed cardioversion (≥48 h from onset) without TEE: anticoagulate for at least 3 wk with a DOAC or warfarin (INR ≥ 2) before cardioversion; continue anticoagulation for at least 4 weeks after cardioversion.
  • Rhythm control is favored over rate control in the following settings:
    • Patients with persistent symptoms causing impaired quality of life or decreased exercise tolerance on rate control therapy,
    • Patients with reduced LVEF
    • Patients diagnosed with AF within the previous year regardless of symptoms.
    • For pharmacologic cardioversion and rhythm maintenance, rhythm control drugs may be tried (see section Selected Medication for Rhythm Control in AF).
    • Stroke risk should be assessed (see section Selected Risk Instrument to Guide Antithrombotic Treatment in AF), and if indicated, antithrombotic therapy should be continued indefinitely after cardioversion due to the high risk for recurrent AF.
    • Catheter or surgical AF ablation is a suitable alternative to drug therapy in most patients for whom rhythm control is desired, and it is recommended as first-line treatment for patients with heart failure with reduced ejection fraction. Catheter ablation is more effective than antiarrhythmic drugs in maintaining sinus rhythm but has not been shown to reduce stroke risk or mortality in older adults.
    • In older adults with AF at high risk for bleeding or with recurrent bleeding during anticoagulant therapy, left atrial appendage occlusion (e.g. Watchman or Amulet device) is an effective alternative to long-term anticoagulation.

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