Management of Atrial Fibrillation

Rate control

Beta blockers

• can help to slow the heart rate at rest and during activity
• may cause side effects such as low blood pressure (hypotension)
• atenolol, acebutolol, metoprolol, nadolol, oxprenolol, and propranolol are licensed to treat atrial fibrillation (AF) (NOT sotalol)
• For people with AF alone
  • atenolol may be preferred because it may be taken once a day and is less expensive than other beta-blockers
  • The usual dose is 50–100 mg a day
• For people who have AF and have had a previous myocardial infarction (without heart failure) 
  • metoprolol (standard release), propranolol (standard release), or atenolol may be preferred
• For people with AF and heart failure 
  • bisoprolol, carvedilol, or nebivolol may be preferred
• For people with AF and diabetes mellitus 
  • a cardioselective beta-blocker (such as atenolol, bisoprolol, metoprolol, nebivolol, and acebutolol [to a lesser extent]) is preferred. Avoid beta-blockers in people who experience frequent hypoglycaemia

Calcium channel blocker

• avoid in heart failure or low blood pressure

Digoxin

• may control the heart rate at rest, but not as well during activity. It is therefore only a possible alternative in people with non‑paroxysmal atrial fibrillation who are sedentary (do no or very little physical exercise). ost people need additional or alternative medications, such as calcium channel blockers or beta blockers.

Monitor

• symptom control, heart rate, and blood pressure
  • Aim for heart rate betwen 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise
• Consider referral for cardioversion for people whose symptoms continue after heart rate has been controlled or for whom a rate‑control strategy has not been successful.

Rhythm control

Cardioversion can be done in two ways:

Electrical cardioversion

• an electrical shock delivered to the heart through paddles or patches placed on chest The shock stops heart's electrical activity for a short moment. The goal is to reset the heart's normal rhythm

Cardioversion with drugs

• anti-arrhythmics to help restore normal sinus rhythm
  • Flecainide
  • Propafenone
  • Amiodarone
  • Sotalol

Anticoagulation

1. Medication options are a DOAC or warfarin
2. Calculate CHA2DS2VASc assessment tool (see bellow or on SystemOne this is calculated automatically)
3. Anticoagulation recommened if CHA2DS2VASc score => 2 for females and =>1 for males 
4. Calculate HAS-BLED score or ORBIT score
   1. A high HAS-BLED score (≥3) or ORBIT score (≥4)
      • should not be used as a reason for stopping oral anticoagulation
      • it is indicative of the need for regular review and followup and highlights modifiable factors
      • reversible risk factors for bleeding may be addressed 
        • eg uncontrolled hypertension, labile INR s of warfarin, concamitant use of NSAID/ Aspirin
   2. Bleeding risk and stroke risk are closely related. Those patients with AF and a high HAS-BLED or ORBIT score derive a higher net clinical benefit from oral anticoagulation when balancing ischaemic stroke against intracranial bleeding.
5. Choose an anticoagulant