Atrial fibrillation (AFib) is a type of arrhythmia, meaning it is an abnormal heart rhythm. In AFib, the electrical signals in the upper chambers of the heart (the atria) become chaotic, causing the atria to beat irregularly and often rapidly, out of sync with the lower chambers (the ventricles)
New-onset atrial fibrillation (AF) requires a structured approach guided by current international guidelines (e.g. ESC 2024, AHA/ACC/HRS 2023). Here’s a summary of evidence-based and guideline-directed management:
Initial Assessment
- Confirm diagnosis with ECG
- Irregularly irregular rhythm, no distinct P waves.
- Identify and treat underlying causes:
- Electrolyte imbalance (K⁺, Mg²⁺)
- Sepsis
- Hypoxia
- Hyperthyroidism
- ACS or heart failure
Stepwise Guideline-Based Management
1. Hemodynamic Stability
- Unstable (e.g., hypotension, angina, pulmonary oedema):
- Immediate synchronised electrical cardioversion (Class I recommendation)
2. Rate vs. Rhythm Control
- Stable patient – Decide between rate and rhythm control
Rate Control (preferred in most elderly or persistent AF)
Goal: HR <110 bpm (lenient) or <80 bpm (strict, in symptomatic patients)
Agents:
- Beta-blockers (e.g., metoprolol, esmolol) – 1st line if no decompensated heart failure
- Non-DHP CCBs (e.g., diltiazem, verapamil) – avoid in HFrEF
- Amiodarone – only in heart failure or hypotension where other agents are contraindicated
- Digoxin – add-on in heart failure or low BP
Rhythm Control
- Consider in:
- Symptomatic despite rate control
- Younger patients
- First episode of AF
- AF with tachycardia-induced cardiomyopathy
- Preference for sinus rhythm
Methods:
- Pharmacologic cardioversion (e.g., flecainide, propafenone, ibutilide, amiodarone)
- Electrical cardioversion
Timing:
- <48 hrs: Safe to cardiovert without anticoagulation (unless CHA₂DS₂-VASc ≥2 in males or ≥3 in females)
- 48 hrs or unknown duration: Require 3 weeks of anticoagulation or TEE to exclude LA thrombus before cardioversion
Anticoagulation – Stroke Prevention
Based on CHA₂DS₂-VASc score:
| Risk Factor | Points |
|---|---|
| C: CHF/LV dysfunction | 1 |
| H: Hypertension | 1 |
| A: Age ≥75 | 2 |
| D: Diabetes | 1 |
| S: Prior stroke/TIA/thromboembolism | 2 |
| V: Vascular disease | 1 |
| A: Age 65–74 | 1 |
| Sc: Sex category (female) | 1 |
Anticoagulation Recommendations:
- Males:
- Score ≥1: Consider anticoagulation
- Score ≥2: Anticoagulation recommended
- Females:
- Score ≥2: Consider
- Score ≥3: Recommend
Options:
- DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin unless contraindicated
Important Points
- Always treat reversible causes (infection, alcohol, surgery, thyroid dysfunction)
- Don’t cardiovert until thrombus ruled out if AF duration >48 hrs or unknown
- Long-term rhythm control can be considered for selected patients (esp. with heart failure or symptoms)
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