Atrial Fibrillation Treatment Options: Guidelines & Drugs
Atrial Fibrillation Treatment: This lecture reviews atrial fibrillation (A-fib) treatment guidelines, algorithm, and management options including drugs, medications, cardioversion, ablation, etc.
Guest Author
Guest Author: Prof. (Dr.) K.V. Sahasranam, MD, DM (Cardio), FACC, FCSI and Retired Senior Consultant Cardiologist
The lecture below was written by guest author Dr. Sahasranam, who is a retired senior consultant cardiologist.
Medical illustrations were created and provided by Dr. Sahasranam and EZmed.
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Atrial Fibrillation Treatment
There are many treatment options for atrial fibrillation, and this lecture will make them easy to understand!
This lecture will review the following about atrial fibrillation treatment:
Medications/Drugs
Anticoagulants (Blood Thinners)
Beta Blockers
Calcium Channel Blockers
Antiarrhythmics
And More!
Stroke Prevention
Heart Rate Control
Heart Rhythm Control
Cardioversion
Ablation
Lifestyle Modification
And so much more!!
STOP! CHECK THIS OUT TOO: If you want a full overview of atrial fibrillation including its definition, symptoms, causes, risk factors, diagnosis, treatment, complications, and more then click here!
Atrial Fibrillation: Treatment guidelines and drug/medication options reviewed including anticoagulation, stroke prevention, beta blockers, calcium channel blockers, antiarrhythmics, rate control, rhythm control, cardioversion, ablation, and more!
Treatment Algorithm
Atrial Fibrillation (also called AFib, A-fib, or AF) is an irregular heart rhythm (arrhythmia) in which the upper chambers of the heart (atria) quiver or beat extremely fast.
The goals of managing AFib are to:
Restore normal sinus rhythm
Eliminate or prevent further episodes of AFib
Re-establish atrioventricular (AV) synchrony
Improve the atrial contribution to stroke volume - “Atrial Kick”
The main methods of management can be remembered as the “ABC of management”
A = Avoiding stroke, Anticoagulants
B = Better symptom management
C = Cardiovascular risk factor & comorbidity management
Let’s walk through the “ABC” approach and algorithm below!
A = Anticoagulants and Avoidance of Stroke
The first treatment approach in the “ABC” algorithm is “Avoidance of Stroke” and “Anticoagulants”.
Stroke in Atrial Fibrillation
Atrial fibrillation increases the risk of stroke by five-fold.
Other systemic thromboembolic complications may also occur.
The atria beat fast and “quiver” during atrial fibrillation, which can cause blood to pool in the atria.
This can lead to thrombus (blood clot) formation within the atria.
The blood clots can potentially leave the heart and travel to other parts of the body (thromboembolism), such as the brain and cause a stroke.
The predictors of stroke and thromboembolic events are:
Age over 70 years
A previous history of stroke or transient ischemic attack (TIA)
Diabetes mellitus
Systemic hypertension
Heart failure
Calculating Stroke Risk
The CHADS-VASc scoring system can be used to identify the risk of stroke in an individual with atrial fibrillation.
Also written as CHA(2)DS(2)-VASc to mark the categories that use 2 points
Atrial Fibrillation: The CHADS-VASc scoring guidelines for stroke risk in AFib and the need for anticoagulation
**Max Score = 9. While points add to 10, there can only be a maximum of 2 points for age.
The CHADS-VASc scoring system is used in non-valvular AFib.
The higher the score, the greater the risk of stroke in the patient.
The score ranges from 0-9, with a maximum score of 9 possible.
**Note: The above scoring system adds up to 10 because there are 2 separate age categories listed. However, the maximum points that can be given for age is 2.
Patients with higher scores may be candidates for anticoagulation (blood thinners) to prevent the risk of stroke in atrial fibrillation.
If the score is 0 in men or 1 in women, then the patient is “low” risk and may not need to take an oral anticoagulant (OAC) as their ischemic stroke and mortality rates are low.
Oral anticoagulation is strongly recommended if the score is ≥ 2 in men or ≥ 3 in women, as patients in this score range are “moderate-high” risk of stroke in atrial fibrillation.
**IMPORTANT: The patient and their provider must weigh the risks and benefits of anticoagulation on a case by case basis to determine whether the individual is a candidate for anticoagulation. The scoring system is a guideline.
There are 2 main methods for preventing stroke in atrial fibrillation:
Anticoagulants
Left Atrial Appendage Exclusion
Let’s review each below!
Anticoagulants in Atrial Fibrillation
As previously mentioned, the “A” for the “ABC management” of atrial fibrillation stands for “Avoidance of Stroke” and “Anticoagulants”.
Anticoagulants are blood thinners that reduce the risk of stroke in individuals who are candidates and are moderate to high risk for stroke in atrial fibrillation.
See CHADS-VASc scoring system above
There are two main types of anticoagulants (blood thinners) used in AFib for stroke prevention.
They include:
Vitamin K Antagonists (VKA)
Warfarin (most common)
Phenindione
Acenocoumarol
Non-Vitamin K Oral Anticoagulants (NOACs)
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
**Note: Heparin can be used as an anticoagulant in atrial fibrillation, especially as a bridging therapy, however it is typically not used longterm (see below).
Vitamin K Antagonists (VKAs)
Vitamin K antagonists (VKAs) are a type of anticoagulant used in AFib for stroke prevention.
Warfarin is the most common VKA used in most countries.
Let’s look at the features of warfarin below.
Warfarin (Coumadin)
A water-soluble compound
Acts by interfering with the synthesis of Vitamin K dependent clotting factors
Factor II (prothrombin)
Factor VII
Factor IX
Factor X
Protein C
Protein S
Without proper synthesis of clotting factors, this in turn thins the blood
Starting Dose = Approximately 5 mg (2-10 mg) by mouth once daily
Maintenance Dose = Typically 5-10 mg by mouth once daily
Dose is monitored using prothrombin time (PT) and international normalized ratio (INR)
PT/INR = Blood test to monitor how well warfarin is working to thin the blood
Normal INR = 1
Therapeutic INR range for AFib = 2.0-3.0
The dose of warfarin is monitored using prothrombin time (PT) and international normalized ratio (INR).
Since PT can be variable depending on the thromboplastin used for the test, INR is used to standardize the value.
A normal INR is 1.
Patients are given warfarin in titrated doses until the INR is maintained at an optimal therapeutic range of 2.0 to 3.0 to ensure adequate anticoagulation.
It takes approximately 3-4 days for the patient to achieve the therapeutic range of 2.0-3.0.
INR should be tested 1-2 times per week initially.
If the patient is stabilized on a particular dose of warfarin, then 2 or 4 week intervals may be acceptable.
Often the patient may not be in the therapeutic range.
To ensure adequate anticoagulation over a prolonged period, the TTR (time in the therapeutic range) is used as an indicator of adequate anticoagulation.
The TTR indicates the percentage of time the patient was in the therapeutic range of 2.0-3.0.
It is calculated using multiple readings of INR.
For optimal anticoagulation the TTR should be ≥ 70%.
Non-Vitamin K Oral Anticoagulants (NOACs)
Non-Vitamin K oral anticoagulants (NOACs) are another type of anticoagulant used for stroke prevention in atrial fibrillation.
You may see NOACS referred to as:
Novel Oral Anticoagulants
New Oral Anticoagulants
Non-Vitamin K Antagonist Oral Anticoagulants
Non-Vitam K Oral Anticoagulants
Direct Oral Anticoagulants (DOACs)
NOACs are the newer anticoagulants which are direct thrombin inhibitors or factor Xa inhibitors.
The NOAC drugs available include:
Dabigatran (Pradaxa)
Direct Thrombin Inhibitor
Given in a dose of 150 mg by mouth twice daily
Rivaroxaban (Xarelto)
Factor Xa Inhibitor
Given in a dose of 20 mg by mouth once daily
Apixaban (Eliquis)
Factor Xa Inhibitor
Given in a dose of 5 mg by mouth twice daily
Edoxaban (Savaysa)
Factor Xa Inhibitor
Given in a dose of 60 mg by mouth once daily
**NOTE: Dosing is not universal for all patients and depends on a number of factors such as renal function among other variables. Appropriate dosing must be determined by the patient’s healthcare provider.
NOACs have several advantages over warfarin:
They have a fixed dose regimen
There is no need for laboratory monitoring with PT/INR
They have very few drug or food interactions
Their onset of action is rapid, hence bridging therapy with heparin is typically not needed
Potential drawbacks of NOACs include:
Higher cost
Need for frequent dosing in some
Gastrointestinal side effects
Atrial Fibrillation: NOAC drug doses and treatment guidelines; Anticoagulation medications used for stroke prevention in AFib
**Cr = serum creatinine; CrCl = creatinine clearance
Low Molecular Weight Heparin (LMWH)
LMWH is used in atrial fibrillation as it has a longer half-life than unfractionated heparin.
It should be injected twice a day and can be done by the patient.
It is often used as a bridging therapy when warfarin must be stopped for any medical or dental procedure or surgery (see below).
As LMWH is costly it is not used for longterm therapy.
Risk of Bleeding with Anticoagulants
There is a risk of bleeding in patients taking an anticoagulant such as warfarin or a NOAC.
To assess the patient's risk of bleeding, a scoring system named the HAS-BLED Score is used.
The higher the score, the higher the chances of bleeding.
A patient with a HAS-BLED Score of ≥ 3 requires close monitoring or alternatives to anticoagulation should be considered.
Atrial Fibrillation: The HAS-BLED score estimates the risk of major bleeding for patients on anticoagulation to assist with atrial fibrillation care
**Abnormal liver function = Cirrhosis or bilirubin > 2x normal with AST/ALT/AP > 3x normal
**Abnormal renal function = Dialysis, transplant, Cr > 2.26 mg/dL or > 200 umol/L
Anticoagulation Reversal
As we mentioned above, there is a risk of bleeding with anticoagulants.
The anticoagulation effects from warfarin or NOACs may need to be reversed, such as in life-threatening bleeds, a planned surgery or procedure, etc.
Warfarin Reversal
When warfarin is stopped, it takes 3 -5 days for the INR to return to normal.
Hence in situations where a surgery or procedure is planned for the patient, bridging therapy with unfractionated or low molecular weight heparin (LMWH) is continued after stopping the VKA.
Heparin is shorter acting than warfarin, and can therefore be stopped closer to the surgery than warfarin can.
The action of warfarin can be reversed by administering Vitamin K at a dose of 2.5-10 mg depending on the INR.
Remember warfarin inhibits the production of vitamin K, so it makes sense that giving vitamin K will reverse the effects of warfarin!
In situations where major/life-threatening bleeding occurs while taking warfarin, 4 - factor prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may also need to be considered to reverse the effects of warfarin.
NOAC Reversal
In a patient scheduled for surgery, discontinuing the drug returns the coagulation system to normal within a few hours.
The anticoagulant effects of NOACs must be reversed immediately when there is severe bleeding.
Andexanet Alfa (coagulation factor Xa recombinant)
Used to reverse the effects of factor Xa inhibitors
Rivaroxaban, Apixaban, and Edoxaban
The dose is 400 or 800 mg as an IV bolus over 15-30 min., followed by an I.V. infusion at 4 or 8 mg/min for up to 120 minutes
Idarucizumab (a monoclonal antibody fragment)
Reverses the anticoagulant effect of Dabigatran
The dose is 5 g IV given in two successive infusions of 2.5 g over 10 minutes.
Left Atrial Appendage Exclusion
As previously mentioned, the “A” for the “ABC management” of atrial fibrillation stands for “Avoidance of Stroke”.
The risk of stroke in atrial fibrillation can be reduced using anticoagulants as previously discussed (see above).
However, anticoagulation may not be an option for patients with contraindications.
Therefore, another option to reduce the risk of stroke is left atrial appendage exclusion/occlusion (LAAO).
The most common location for a left atrial blood clot to occur in atrial fibrillation is the left atrial appendage (LAA).
The LAA can be isolated or excluded to prevent the thrombus (blood clot) from traveling (embolus) to other parts of the body, such as the brain which could cause a stroke.
Indications for LAA exclusion:
Patients at a high risk of stroke with a contraindication for anticoagulants
Patients on dialysis
Patients with a high HAS-BLED or CHADS-VASc score
Patients with permanent AFib
There are two techniques to achieve this:
Surgical
LAA amputation followed by epicardial closure with sutures is the most effective method.
An exclusion device named Atriclip LAA Exclusion device is applied to the outside of the LAA to clip and occlude the appendage. This can be done as a minimally invasive surgical procedure.
Percutaneous
This is also called Endocardial LAA occlusion.
The devices are introduced percutaneously during cardiac catheterization, and they expand in the appendage to plug them.
The Watchman LAA closure device and the Amplatzer Cardiac Plug are devices used for LAA exclusion.
B = Better Symptom Management
The “B” for the “ABC management” of atrial fibrillation stands for “Better Symptom Management”
Better symptom management in AFib involves:
Heart rate control
Heart rhythm control
It has been found in recent studies that the rate and rhythm control strategies have the same incidence of total mortality, stroke rate and quality of life.
1. Rate Control in Atrial Fibrillation
An ideal rate control for AFib aims at a resting heart rate of 60-75 beats per minute and a rate of 90-110 beats per minute during moderate exercise as assessed by an ambulatory Holter monitor.
Rate control is achieved by pharmacological drugs.
Example drugs used in rate control of AFib include:
Beta Blockers
Metoprolol, bisoprolol, atenolol, esmolol, nebivolol, carvedilol
Calcium Channel Blockers (non-dihydropyridines)
Diltiazem, verapamil
Digoxin
Amiodarone
Digitalis is useful in rate control at rest but not during exercise. It is ideal in heart failure.
*Note: Many medications used for rate control are also antiarrhythmics (see below).
Rate control strategy alone is preferable in :
Longstanding, recurrent atrial fibrillation
Patients over the age of 80
Intolerable side effects of antiarrhythmic drug (i.e. proarrhythmias)
Asymptomatic AFib
In poorly controlled, symptomatic AFib, the AV node is ablated, and ventricular pacing done by implanting a permanent pacemaker - “Pace & Ablate Strategy”.
Atrial Fibrillation: Beta blocker doses and choices; Treatment guidelines for rate control in AFib
Atrial Fibrillation Treatment: Rate control drug/medication guidelines using calcium channel blockers (verapamil, diltiazem), digoxin, or amiodarone.
2. Rhythm Control in Atrial Fibrillation
Rhythm control in atrial fibrillation can be achieved by:
Cardioversion
Electrical Cardioversion
Pharmacological Cardioversion
Ablation Procedures
Surgical Rhythm Control
Antiarrhythmic (AA) Medications
Amiodarone
Flecainide
Propafenone
Disopyramide
Sotalol
Ibutilide
Dofetilide
Procainamide
**Note: Many of the antiarrhythmic drugs listed above can be used to terminate AFib as well as for long term maintenance of sinus rhythm after conversion of AFib (see below).
Rhythm control is preferred in the following circumstances:
Newly diagnosed AFib
High cardiovascular risk patients – Those above age 75, prior stroke or TIA, hypertension, diabetes, severe CAD, CKD, etc.
Persistent symptoms
Inadequate rate control
Heart failure
Tachycardia mediated cardiomyopathy
Younger patients < 65 years of age
2.1. Cardioversion
Definition: Cardioversion is the process of restoring normal sinus rhythm (NSR) in a patient with a tachyarrhythmia.
In AFib, cardioversion is performed when:
Hemodynamic instability, hypotension, ongoing angina, pulmonary edema, or heart failure occurs
AFib is highly symptomatic
Long term maintenance of sinus rhythm is expected
Catheter ablation is planned
Cardioversion attempts to convert the rhythm from AFib to sinus rhythm.
There are two methods of cardioversion:
Electrical Cardioversion
Pharmacological Cardioversion
Electrical Cardioversion (EC)
Electrical cardioversion, also called direct current (DC) cardioversion, is used for abrupt termination of the arrhythmia.
The electric shock given is synchronized with the QRS complex of the patient to prevent it from falling on the vulnerable period of the T wave.
The cardioversion is performed under procedural sedation usually with an intravenous dose of midazolam.
DC cardioversion is usually started with a low dose of 50 joules and increased if necessary.
Atrial arrhythmias usually only require low energy shocks for conversion.
EC is preferred for the first episode of AFib.
It is superior to pharmacological cardioversion, and the need for prolonged monitoring during antiarrhythmic (AA) therapy can be obviated.
AA therapy is often initiated prior to EC as successful cardioversion is more likely and recurrences of AFib is less likely.
After successful EC, maintenance AA therapy is necessary to sustain sinus rhythm (see below).
Pharmacological Cardioversion
Pharmacological cardioversion is the conversion of AFib to sinus rhythm using antiarrhythmic drugs.
This is indicated only in patients who are hemodynamically stable.
Flecainide, propafenone, ibutilide, dofetilide, procainamide and amiodarone are example medications used.
Procainamide and quinidine which were used previously are no longer used as first line drugs for cardioversion.
Patients are put on oral anticoagulant therapy for 3-4 weeks prior to cardioversion.
Atrial Fibrillation Cardioversion: Drug and medication options with dosing guidelines for pharmacological cardioversion in the treatment of atrial fibrillation.
2.2. Ablation Procedures
Symptomatic patients in whom the quality of life is affected and those who do not respond to antiarrhythmic drugs are potential candidates for ablation procedures.
It is contraindicated when a left atrial thrombus is present.
Catheter ablation is performed using radiofrequency, which creates tiny scars in the heart to block the electrical signals causing atrial fibrillation.
Electrical isolation of the pulmonary veins is done during catheter ablation.
Cryoballoon ablation is used to isolate the pulmonary veins using cryoenergy.
2.3. Surgical Procedures
The Cox-Maze procedure involves multiple atrial incisions which are sewed, thus isolating the pulmonary veins, and creating lines of scar tissue that block abnormal impulses that cause atrial fibrillation.
The right and left atrial appendages are removed during the surgery.
For surgical ablation, radiofrequency energy, cryoenergy, microwave energy, laser and high intensity focussed ultrasound have been used.
Surgery for AFib is usually done along with open heart surgery as for CAD or valvular disease.
It is also indicated when catheter ablation fails.
2.4. Long Term Maintenance of Sinus Rhythm after Conversion
The main antiarrhythmic drugs used for long term maintenance of sinus rhythm after conversion of AFib are amiodarone, flecainide, propafenone, disopyramide and sotalol.
Atrial Fibrillation Treatment: Antiarrhythmic medication options, drug list, and dosing guidelines for long-term maintenance of sinus rhythm in AFib using amiodarone, flecainide, sotalol, etc.
C = Cardiovascular Risk Factor & Comorbidity Management
The “C” for the “ABC management” of atrial fibrillation stands for “Cardiovascular Risk Factor and Comorbidity Management”.
Adequate management of cardiovascular risk factors and unhealthy lifestyle form the third important aspect of AFib management and include:
Obesity is managed by an intense weight reduction regimen
High blood pressure should be properly controlled
The blood pressure should be kept ≤ 130/80 mmHg
Diabetes mellitus and dyslipidemia should be optimally controlled
Alcohol excess should be avoided - Abstinence is ideal
Moderate intensity physical exercise and being physically active is encouraged
Heart failure should be optimally treated and controlled
Coronary artery disease should be managed appropriately with medications, angioplasty, or coronary artery bypass graft (CABG)
Obstructive sleep apnea needs continuous positive airway pressure ventilation (CPAP) or other measures to prevent AFib and its recurrences
Atrial Fibrillation Treatment Options. Guidelines and algorithm for the treatment of AFib using the mnemonic “ABC”; Includes anticoagulation, rate control, rhythm control, and comorbidity management.
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