AF treatment

Treatment goals in atrial fibrillation

After a patient is diagnosed with atrial fibrillation (AF), the ideal treatment goals include:

• Restoring the heart to a normal rhythm (called rhythm control)
• Reducing an overly high heart rate (called rate control)
• Preventing blood clots (called prevention of thromboembolism such as stroke)
• Managing risk factors for stroke
• Preventing additional heart rhythm problems
• Preventing heart failure

Preventing blood clots using anticoagulants

In this video, Professor Tatjana Potpara from the School of Medicine, University of Belgrade in Serbia, and co-author of the 2020 ESC guidelines for the diagnosis and management of AF, elaborates on the recommendations for oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation (AF).

Heart rate control in atrial fibrillation

Heart rate control is only suitable for some atrial fibrillation (AF) patients; this section suggests when heart rate control may be appropriate.

Electrical cardioversion in atrial fibrillation

Electrical cardioversion is a cornerstone of atrial fibrillation (AF) care, but patients still need effective anticoagulation and pretreatment. 

1. Pharmacological cardioversion in atrial fibrillation
2. Long-term antiarrhythmic drugs (AADs)

Pharmacological cardioversion in atrial fibrillation

Find out which patients may be more suitable for pharmacological than electrical cardioversion.

Invasive treatment for atrial fibrillation

Invasive treatments offer an option when drugs are contraindicated, poorly tolerated or not fully effective. The ESC/EHRA 2020 guidelines, for instance, suggest considering atrioventricular node ablation to control heart rate in patients unresponsive or intolerant to intensive rate and rhythm control therapy. These patients will, however, become pacemaker dependent¹. 

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References

1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Euro Heart J. 2021;42(5):373–498.
2. Camm AJ, Naccarelli GV, Mittal S, Crijns HJGM, Hohnloser SH, Ma C-S, et al. The Increasing Role of Rhythm Control in Patients With Atrial Fibrillation. Journal of the American College of Cardiology. 2022;79(19):1932-1948.
3. Rogers PA, Bernard ML, Madias C, Thihalolipavan S, Mark Estes NA, Morin DP. Current evidence-based understanding of the epidemiology, prevention, and treatment of atrial fibrillation. Curr Probl Cardiol. 2018;43(6):241-283.
4. Lip GYH. The ABC pathway: An integrated approach to improve AF management. Nature Reviews Cardiology. 2017;14(11):627-628.
5. Oladiran O, Nwosu I. Stroke risk stratification in atrial fibrillation: a review of common risk factors. Journal of Community Hospital Internal Medicine Perspectives. 2019;9(2):113-120.
6. Proietti M, Romiti GF, Olshansky B, Lane DA, Lip GYH. Improved Outcomes by Integrated Care of Anticoagulated Patients with Atrial Fibrillation Using the Simple ABC (Atrial Fibrillation Better Care) Pathway. American Journal of Medicine. 2018;131(11):1359-1366.e1356.
7. Pastori D, Farcomeni A, Pignatelli P, Violi F, Lip GYH. ABC (Atrial fibrillation Better Care) Pathway and Healthcare Costs in Atrial Fibrillation: The ATHERO-AF Study. American Journal of Medicine. 2019;132(7):856-861.
8. Romiti GF, Pastori D, Rivera-Caravaca JM, Ding WY, Gue YX, Menichelli D, et al. Adherence to the 'Atrial Fibrillation Better Care' Pathway in Patients with Atrial Fibrillation: Impact on Clinical Outcomes-A Systematic Review and Meta-Analysis of 285,000 Patients. Thrombosis and Haemostasis. 2021.
9. Romiti GF, Proietti M, Bonini N, Ding WY, Boriani G, Huisman MV, et al. Adherence to the Atrial Fibrillation Better Care (ABC) pathway and the risk of major outcomes in patients with atrial fibrillation: a post-hoc analysis from the prospective GLORIA-AF Registry. eClinicalMedicine. 2023;55:101757.
10. Levent F, Kanat S, Tutuncu A. Predictive Value of C2HEST Score for Atrial Fibrillation Recurrence Following Successful Cryoballoon Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation. Angiology. 2023;74(3):273-281.
11. Krittayaphong R, Kanjanarutjawiwat W, Wisaratapong T, Lip GY. Improving risk prediction for death, stroke and bleeding in Asian patients with atrial fibrillation. European Journal of Clinical Investigation. 2023;53(2):e13886.
12. Wollert KC, Kempf T, Wallentin L. Growth differentiation factor 15 as a biomarker in cardiovascular disease. Clinical Chemistry. 2017;63(1):140-151.
13. Ulimoen SR, Enger S, Carlson J, Platonov PG, Pripp AH, Abdelnoor M, et al. Comparison of four single-drug regimens on ventricular rate and arrhythmia-related symptoms in patients with permanent atrial fibrillation. American Journal of Cardiology. 2013;111(2):225-230.
14. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart R. Circulation. 2019;140(2):e125-e151.
15. Mackman N, Tilley Rachel E, Key Nigel S. Role of the extrinsic pathway of blood coagulation in hemostasis and thrombosis. Arterioscler Thromb Vasc Biol. 2007;27(8):1687-1693.
16. Saraf K, Morris P, Garg P, Sheridan P, Storey R. Non-vitamin K antagonist oral anticoagulants (NOACs): Clinical evidence and therapeutic considerations. Postgrad Med J. 2014;90(1067):520-528.
17. Pirmohamed M. Warfarin: almost 60 years old and still causing problems. Br J Clin Pharmacol. 2006;62(5):509-511.
18. Hoffman M, Monroe DM. Impact of non-vitamin K antagonist oral anticoagulants from a basic science perspective. Arterioscler Thromb Vasc Biol. 2017;37(10):1812-1818.
19. Hankey GJ. Stroke. Lancet. 2017;389(10069):641-654.
20. Hayden D, Hannon N, Callaly E, Ní Chróinín D, Horgan G, Kyne L, et al. Rates and determinants of 5-year outcomes after atrial fibrillation–related stroke. Stroke. 2015;46(12):3488-3493.
21. Amerena J, Ridley D. An update on anticoagulation in atrial fibrillation. Heart Lung Circ. 2017;26(9):911-917.
22. Almutairi AR, Zhou L, Gellad WF, Lee JK, Slack MK, Martin JR, et al. Effectiveness and safety of non–vitamin k antagonist oral anticoagulants for atrial fibrillation and venous thromboembolism: A systematic review and meta-analyses. Clin Ther. 2017;39(7):1456-1478.e1436.
23. Bhatt HV, Fischer GW. Atrial fibrillation: Pathophysiology and therapeutic options. J Cardiothor Vasc An. 2015;29(5):1333-1340.
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25. Lip GYH, Agnelli G. Edoxaban: A focused review of its clinical pharmacology. Eur Heart J. 2014;35(28):1844-1855.
26. Edwina AE, Dia N, Dreesen E, Vanassche T, Verhamme P, Spriet I, et al. Insights into the Pharmacokinetics and Pharmacodynamics of Direct Oral Anticoagulants in Older Adults with Atrial Fibrillation: A Structured Narrative Review. Clinical Pharmacokinetics. 2023:1-23.
27. Zhao Y, Guo M, Li D, Xu W, Pan C, He C, et al. Pharmacokinetics and dosing regimens of direct oral anticoagulants in morbidly obese patients: an updated literature review. Clinical and Applied Thrombosis/Hemostasis. 2023;29:10760296231153638.
28. Pan K-L, Singer DE, Ovbiagele B, Wu Y-L, Ahmed MA, Lee M. Effects of non-vitamin k antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and valvular heart disease: A systematic review and meta-analysis. J Am Heart Assoc. 2017;6(7):e005835-e005835.
29. Kovacs RJ, Flaker GC, Saxonhouse SJ, Doherty JU, Birtcher KK, Cuker A, et al. Practical management of anticoagulation in patients with atrial fibrillation. J Am Coll Cardiol. 2015;65(13):1340-1360.
30. Mitchell AP, Persaud S, Chimonas S, Salner AL, Palyca P, Farooki A, et al. Barriers to guideline-concordant use of bone modifying agents for prostate cancer. Journal of Clinical Oncology. 2023;41(6_suppl):68-68.
31. Zhao Y, Zhu L, Yang Y, Gao H, Zhang R. Safety of direct oral anticoagulants in patients with liver disease: a systematic review and meta-analysis. Acta Clin Belg. 2022:1-11.
32. Lawal OD, Aronow HD, Shobayo F, Hume AL, Taveira TH, Matson KL, et al. Comparative effectiveness and safety of direct oral anticoagulants and warfarin in patients with atrial fibrillation and chronic liver disease: a nationwide cohort study. Circulation. 2023;147(10):782-794.
33. Al-Hussainy N, Kragholm KH, Lundbye-Christensen S, Torp-Pedersen C, Pareek M, Therkelsen SK, et al. Safety and efficacy of direct oral anticoagulants in patients with anaemia and atrial fibrillation: an observational nationwide Danish cohort study. European Heart Journal-Quality of Care and Clinical Outcomes. 2022;8(8):840-851.
34. Renda G, Ricci F, Giugliano RP, De Caterina R. Non–vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease. J Am Coll Cardiol. 2017;69(11):1363-1371.
35. Gerfer S, Djordjevic I, Eghbalzadeh K, Mader N, Wahlers T, Kuhn E. Direct oral anticoagulation in atrial fibrillation and heart valve surgery—a meta-analysis and systematic review. Ther Adv Cardiovasc Dis. 2022;16:17539447221093963.
36. Waranugraha Y, Rizal A, Syaban MFR, Faratisha IFD, Erwan NE, Yunita KC. Direct comparison of non-vitamin K antagonist oral anticoagulant versus warfarin for stroke prevention in non-valvular atrial fibrillation: a systematic review and meta-analysis of real-world evidences. Egyptian Heart Journal. 2021;73(1).
37. Chen X, Wang L, Li H, Huang W, Zhao L, Guo W. Comparative differences in the risk of major gastrointestinal bleeding among different direct oral anticoagulants: An updated traditional and Bayesian network meta-analysis. Frontiers in pharmacology. 2023;13:1049283.
38. Barakakis PA, Kokkinidis DG, Li W, Nagraj S, Peppas S, Kladas M, et al. Safety of Direct Oral Anticoagulants for Gastrointestinal Hemorrhage in Patients With Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-analysis of Real-world Studies. Journal of Clinical Gastroenterology.10.1097.
39. Moudallel S, van den Eynde C, Malý J, Rydant S, Steurbaut S. Retrospective analysis of gastrointestinal bleedings with direct oral anticoagulants reported to EudraVigilance. Naunyn-Schmiedeberg's Archives of Pharmacology. 2023:1-11.
40. Lavalle C, Mariani MV, Piro A, Magnocavallo M, Vetta G, Trivigno S, et al. Five Years of Direct Oral Anticoagulants Use in Italy: Adverse Drug Reactions from the Italian National Pharmacovigilance Network. Journal of Clinical Medicine. 2022;11(11):3207.
41. Sairaku A, Nakano Y. Increased major bleeding incidence in atrial fibrillation patients with apixaban: a review of Japanese post-marketing surveillance studies of direct oral anticoagulants. European Journal of Clinical Pharmacology. 2023:1-10.
42. Capodanno D, Alfonso F, Levine GN, Valgimigli M, Angiolillo DJ. ACC/AHA versus ESC guidelines on dual antiplatelet therapy. Journal of the American College of Cardiology. 2018;72(23):2915-2931.
43. Capodanno D, Angiolillo DJ. Management of antiplatelet and anticoagulant therapy in patients with atrial fibrillation in the setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions. Circulation: Cardiovascular Interventions. 2014;7(1):113-124.
44. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal. 2019;40(2):87-165.
45. De Luca L, Mistrulli R, Veneziano FA, Grigioni F, Volpe M, Musumeci F, et al. Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. Journal of Clinical Medicine. 2022;11(3):512.
46. Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing Percutaneous Coronary Intervention. Circulation. 2018;138(5):527-536.
47. Oldgren J, Steg PG, Hohnloser SH, Lip GYH, Kimura T, Nordaby M, et al. Dabigatran dual therapy with ticagrelor or clopidogrel after percutaneous coronary intervention in atrial fibrillation patients with or without acute coronary syndrome: a subgroup analysis from the RE-DUAL PCI trial. European Heart Journal. 2019;40(19):1553-1562.
48. Mehran R, Kalkman DN, Angiolillo DJ. Atrial fibrillation, with ACS and PCI: walking a tightrope. European Heart Journal. 2019;40(19):1563-1566.
49. Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R, et al. Antithrombotic therapy after Acute Coronary Syndrome or PCI in atrial fibrillation. New England Journal of Medicine. 2019;380(16):1509-1524.
50. Lopes RD, Hong H, Harskamp RE, Bhatt DL, Mehran R, Cannon CP, et al. Safety and efficacy of antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention. JAMA Cardiology. 2019.
51. Laugesen EK, Staerk L, Carlson N, Kamper AL, Olesen JB, Torp-Pedersen C, et al. Non-vitamin K antagonist oral anticoagulants vs. vitamin-K antagonists in patients with atrial fibrillation and chronic kidney disease: A nationwide cohort study. Thrombosis Journal. 2019;17(1).
52. Chan KE, Giugliano RP, Patel MR, Abramson S, Jardine M, Zhao S, et al. Nonvitamin K Anticoagulant Agents in Patients With Advanced Chronic Kidney Disease or on Dialysis With AF. Journal of the American College of Cardiology. 2016;67(24):2888-2899.
53. Rhee T-M, Lee S-R, Choi E-K, Oh S, Lip GY. Efficacy and Safety of Oral Anticoagulants for Atrial Fibrillation Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Frontiers in Cardiovascular Medicine. 2022;9.
54. Reinecke H, Engelbertz C, Bauersachs R, Breithardt G, Echterhoff H-H, Gerß J, et al. A Randomized Controlled Trial Comparing Apixaban With the Vitamin K Antagonist Phenprocoumon in Patients on Chronic Hemodialysis: The AXADIA-AFNET 8 Study. Circulation. 2023;147(4):296-309.
55. Park H, Yu HT, Kim T-H, Park J, Park J-K, Kang K-W, et al. Oral Anticoagulation Therapy in Atrial Fibrillation Patients with Advanced Chronic Kidney Disease: CODE-AF Registry. Yonsei Med J. 2023;64(1):18.
56. Andò G, Capranzano P. Non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients with chronic kidney disease: A systematic review and network meta-analysis. International Journal of Cardiology. 2017;231:162-169.
57. Yao X, Hu Q, Liu X, Ling Q, Leng Y, Zhao H, et al. Atrial fibrillation and breast cancer—Vicious twins? A systematic review and meta-analysis. Frontiers in Cardiovascular Medicine. 2023;10.
58. Pastori D, Menichelli D, Di Rocco A, Farcomeni A, Sciacqua A, Pignatelli P, et al. Bleeding and thrombotic events in atrial fibrillation patients with cancer: a systematic review and meta-analysis. Internal and Emergency Medicine. 2022:1-11.
59. Ay C, Grilz E, Nopp S, Moik F, Königsbrügge O, Klimek P, et al. Atrial fibrillation and cancer: prevalence and relative risk from a nationwide study. Research and Practice in Thrombosis and Haemostasis. 2023;7(1):100026.
60. Mehta HB, An H, Ardeshirrouhanifard S, Raji MA, Alexander GC, Segal JB. Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation. Circ Cardiovasc Qual Outcomes. 2022;15(12):e008951.
61. Rutherford O-CW, Jonasson C, Ghanima W, Söderdahl F, Halvorsen S. Effectiveness and safety of oral anticoagulants in elderly patients with atrial fibrillation. Heart. 2022;108(5):345-352.
62. Ehrlinder H, Orsini N, Modig K, Wallén H, Gigante B. Antithrombotic treatment switching in elderly patients with atrial fibrillation and the risk of thromboembolism, bleeding, and cardiac death. Research and Practice in Thrombosis and Haemostasis. 2022;6(7):e12823.
63. Hu J, Zhou Y, Cai Z. Outcome of novel oral anticoagulant versus warfarin in frail elderly patients with atrial fibrillation: a systematic review and meta-analysis of retrospective studies. Acta Clin Belg. 2023:1-11.
64. Lip GYH, Tse HF, Lane DA. Atrial fibrillation. Lancet. 2012;379(9816):648-661.
65. Dan G-A, Dan AR, Ivanescu A, Buzea AC. Acute rate control in atrial fibrillation: an urgent need for the clinician. Eur Heart J Suppl. 2022;24(Supplement_D):D3-D10.
66. Gutierrez C, Blanchard DG. Diagnosis and treatment of atrial fibrillation. Am Fam Physician. 2016;94(6):442-452.
67. Elgaard AF, Dinesen PT, Riahi S, Hansen J, Lundbye‐Christensen S, Thøgersen AM, et al. External cardioversion of atrial fibrillation and flutter in patients with cardiac implantable electrical devices. Pacing Clin Electrophysiol. 2023;46(2):108-113.
68. Um KJ, McIntyre WF, Mendoza PA, Ibrahim O, Nguyen ST, Lin SH, et al. Pre-treatment with antiarrhythmic drugs for elective electrical cardioversion of atrial fibrillation: a systematic review and network meta-analysis. EP Europace. 2022;24(10):1548-1559.
69. Nguyen ST, Belley-Côté EP, Ibrahim O, Um KJ, Lengyel A, Adli T, et al. Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis. Europace. 2023;25(2):318-330.
70. Eid M, Jazar DA, Medhekar A, Khalife W, Javaid A, Ahsan C, et al. Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials. IJC Heart & Vasculature. 2022;43:101129.
71. Prasai P, Shrestha DB, Saad E, Trongtorsak A, Adhikari A, Gaire S, et al. Electric Cardioversion vs. Pharmacological with or without Electric Cardioversion for Stable New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2023;12(3):1165.
72. Johnston BW, Chean CS, Duarte R, Hill R, Blackwood B, McAuley DF, et al. Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis. British Journal of Anaesthesia. 2022;128(5):759-771.
73. Rillig A, Borof K, Breithardt G, Camm AJ, Crijns HJGM, Goette A, et al. Early Rhythm Control in Patients With Atrial Fibrillation and High Comorbidity Burden. Circulation. 2022;146(11):836-847.
74. Cacioppo F, Schwameis M, Schuetz N, Oppenauer J, Schnaubelt S, Simon A, et al. Cardioversion of Post-Ablation Atrial Tachyarrhythmia with Ibutilide and Amiodarone: A Registry-Based Cohort Study. International Journal of Environmental Research and Public Health. 2022;19(11):6606.
75. Lévy S, Steinbeck G, Santini L, Nabauer M, Maceda DP, Kantharia BK, et al. Management of atrial fibrillation: two decades of progress—a scientific statement from the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol. 2022;65(1):287-326.
76. Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS). Giornale italiano di cardiologia (2006). 2019;20(7):1-61.
77. Hautmann M, Zacher M, Fuchs S, Pérez CM, Ahmidou A, Kerber S, et al. Left atrial appendage thrombus formation, potential of resolution and association with prognosis in a large real-world cohort. Scientific Reports. 2023;13(1).
78. Safavi-Naeini P, Rasekh A. Update on atrial fibrillation. Tex Heart I J. 2016;43(5):412-414.
79. Chen C, Cheng K, Gao X, Zou T, Pang Y, Ling Y, et al. Cryoballoon ablation for atrial fibrillation in patients with heart failure with mildly reduced and preserved ejection fraction. ESC Heart Failure. 2023;10(1):518-531.