Atrial fibrillation

Rate control and maintenance of sinus rhythm

NICE updated its guidelines on the management of atrial fibrillation (AF) in 2021. The following is also based on the joint American Heart Association (AHA), American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines

Patients presenting acutely with AF

If a patient has signs of haemodynamic instability (e.g. hypotension, heart failure) they should be electrically cardioverted, as per the peri-arrest tachycardia guidelines.

For haemodynamically stable patients, the management depends on how acute the AF is:

• < 48 hours: rate or rhythm control
• ≥ 48 hours or uncertain (e.g. patient not sure when symptoms started): rate control
  • if considered for long-term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks
• anticoagulation
  • all patients with new-onset AF require anticoagulation, regardless of onset
  • long-term anticoagulation is based on the CHADSVASc score

Atrial fibrillation - e Image used on license from Dr Smith, University of Minnesota

Rate control

Rate control should be offered as the first-line treatment strategy for atrial fibrillation except in people:

• whose atrial fibrillation has a reversible cause
• who have heart failure thought to be primarily caused by atrial fibrillation
• with new-onset atrial fibrillation (< 48 hours)
• 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

Medications

Agents used to control rate in patients with atrial fibrillation

• beta-blockers
  • a common contraindication for beta-blockers is asthma