Atrial Fibrillation


Management of Atrial Fibrillation

Among the most important decisions that must be made by a patient and care provider when choosing a treatment plan for AF is the choice between rate and rhythm control. Rate control is typically a simpler strategy than rhythm control, involving the use of generally less toxic medications and fewer medical procedures, although rate control strategies can result in adverse drug side effects and toxicities and, in some cases, may require interventions such as pacemaker implantation and atrioventricular (AV) nodal ablation
  • Rate control
    • medicines to control the heart rate
  • Rhythmn control (generally for people whom a rate‑control strategy has not been successful)
    • anti-arrhythmic medications 
    • cardioversion – where the heart is given a controlled electric shock to restore normal rhythm
    • catheter ablation – where the area inside the heart that's cusing the abnormal heart rhythm is destroyed using radiofrequency energy; afterwards you may then need to have a pacemaker fitted to help your heart beat regularly
  • Stroke prevention
    • medicines to prevent a stroke - anticoagulation

Rate control

Offer rate control as the first‑line strategy to people with atrial fibrillation, except in people:
  • whose atrial fibrillation has a reversible cause
    • eg hyperthyroidism, myocarditis, pericarditis, myocardial infarction, cardiac surgery, pulmonary embolism, pneumonia, chest malignancy, excess alcohol or caffeine use, stroke
  • who have heart failure thought to be primarily caused by atrial fibrillation
  • with new‑onset atrial fibrillation
  • with 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
  1. Monotherapy: Offer either a standard beta‑blocker (that is, a beta‑blocker other than sotalol) or a rate‑limiting calcium‑channel blocker based on the person's symptoms, heart rate, comorbidities and preferences. Consider digoxin monotherapy for people with non‑paroxysmal atrial fibrillation only if they are sedentary (do no or very little physical exercise)
  2. Dual therapy: When monotherapy does not control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider combination therapy with any 2 of: beta‑blocker, diltiazem and digoxin
  3. Triple therapy: When rates are not adequately controlled on a dual therapy then add a third rate-control agent
  4. Some patients will not achieve adequate heart rate control with pharmacologic therapies. Alternative therapies with either rhythm control strategy or nonpharmacologic therapies to control the ventricular rate should be considered to prevent development of a tachycardiomyopathy.
Medication Dose Monitoring When to use/avoid Mode of action  Additional info

Beta blockers




Bisoprolol 2.5mg-10mg od 




heart rate and/or do an ECG 

preferred in patients with coronary heart disease and heart failure

may cause hypotension

blocks the effects of adrenaline and other related hormones on the heart to slow down heart rate  
Calcium channel blockers 

diltiazem 120mg od or 90mg bd

verapamil 120mg od or 40mg bd or tds
heart rate, blood pressure & ECG

preferred in patients with reactive airway disease or chronic obstructive pulmonary disease and in patients who do not tolerate beta-blocker therapy

avoid in heart failure or hypotension

reducing the movement of calcium into the AV-node and in the arteries and veins. This causes the force and rate of the heart's contractions to decrease. This relaxes the arteries and then reduces blood pressure (BP). They can be used on their own or with other anti-arrhythmic drugs to enhance their effects different preparations will have different effects so stick to the same brand
Digoxin 62.5–250 mcg od reduce dose in the elderly 

adjust dose according to renal function and initial loading dose

if digoxin toxicoty is suspected then blood test should be taken six to ten hours after intake of medication

may control the heart rate at rest, but not as well during activity - preferred in patients with sedentary lifestyle (no excercise)


may help heart beat stronger and improve the symptoms of heart failure

works by slowing the electrical impulses through the AV-node, helping to control how fast the ventricles contract symptoms of digoxin toxicity:
  • loss of appetite
  • nausea
  • vomiting
  • diarrhoea
  • blurred vision
  • visual disturbances 
  • confusion 
  • drowsiness
  • dizziness

Rhythm control 

Consider pharmacological and/or electrical rhythm control for people with atrial fibrillation whose symptoms continue after heart rate has been controlled or for whom a rate‑control strategy has not been successful

Anti-arrhythmic medications  

Medication Dose Monitoring When to use/avoid Mode of action  Additional info
Flecainide 50mg bd up to 200mg bd depending on symptoms and ECG  regular ECGs one week after starting flecainide and then after each increase in dosage

very effective in treating episodes of AF and is often better tolerated than some of the other anti-arrhythmic medications

more obvious effect with faster heart rates, which makes it very useful to control fast episodes of AF

only given to people who have a normal functioning heart

sodium channel-blocking drug; slows the conduction (carrying the electrical impulses) within the heart the addition of a beta blocker or calcium channel blocker will protect the lower chambers of the heart (ventricles) from contracting too quickly
Sotalol 40mg bd up to 160mg bd

ECG one week after initiation and after each dose increase to ensure the conduction in heart has not slowed down too much

monitor symptoms

  low doses acts like a beta blocker, higher doses acts like an anti-arrhythmic by blocking potassium channels and slowing conduction in the heart can also be pro-arrhythmic- this will show up on ECG 
Amiodarone 200mg tds 7/7 then bd 7/7 then od 

chest X-ray and monitor LFT and TFT when starting then every six months

for patients with structural heart disease or who have tried other AF medications without success


works in a similar way to sotalol by blocking potassium channels and slowing conduction within the heart

very effective at maintaining sinus (normal) rhythm


interacts with many medications and herbal medicines


150 mg tds pc inceased at intervals of at least 3 days (5 days for elderly) to 300mg bd max 300mg tds

reduce total daily dose for patients under 70 kg

monitor ECG and blood pressure, if QRS interval prolonged by more than 20%, reduce dose or discontinue until ECG returns to normal limits

  works directly on the heart tissue and will slow the nerve impulses in the heart  

Electrical cardioversion

  • an electrical shock is delivered to heart through paddles or patches placed on chest
  • the shock stops heart's electrical activity for a short moment
  • goal is to reset heart's normal rhythm
  • after electrical cardioversion, anti-arrhythmic medications may be needed to help prevent future episodes of AF 


see seperate section on anticoagulation 

'Pill in the pocket'

  • patient carries a tablet which they take as soon as they realise they are having an AF episode
  • In paroxysmal AF episodes may be infrequent
  • can be flecainide, a beta blocker or a calcium channel blocker
  2. NICE

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