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Newly discovered AF

Paroxysmal

Persistent

Look for the presence of one of these severe symptoms Hypotension Heart failure Angina pectoris Severe symptoms absent: No therapy needed Severe symptoms present: Attempt direct-current cardioversion

Permanent AF

Anticoagulation as needed based on the risk of stroke Click here for the risk of stroke and anticoagulation therapy Control heart rate as an intial method to terminate AF Click here for recommended pharmacological agents used for rate control

Anticoagulation as needed based on the risk of stroke Click here for the risk of stroke and anticoagulation therapy Recommended in all cases except lone AF (I A) Measure INR weekly initially, then monthly when stable (I A) Reassess need for anticoagulation at periodic intervals (IIa C)

Anticoagulation as needed based on the risk of stroke Click here for the risk of stroke and anticoagulation therapy Control heart rate as an intial method to terminate AF Click here for recommended pharmacological agents used for rate control

Antiarrhythmic Drug Therapy in Atrial Fibrillation

Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation:

Maintenance of sinus rhythm

No (or minimal) heart disease

Hypertension

Coronary artery disease

Heart failure

Dronedarone Flecainide Propafenone Sotalol

Substantial LVH

Dronedarone Dofetilide Sotalol

Amiodarone Dofetilide

Amiodarone Dofetilide

Catheter ablation

No

Yes

Amiodarone

Catheter ablation

Catheter ablation

Dronedarone Flecainide Propafenone Sotalol

Amiodarone

Catheter ablation

Amiodarone Dofetilide

Catheter ablation

Drugs are listed alphabetically and not in order of suggested use.
The seriousness of heart disease progresses from left to right, and selection of therapy in patients with multiple conditions depends on the most serious condition present.
LVH indicates left ventricular hypertrophy.
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.

Pharmacological Cardioversion

Cardioversion upto7 Days

Drug	Class of Recommendation/ Level of Evidence	Dosage
Agents with proven efficacy
Dofetilide	I A	Creatinine clearance(ml/min) Dose (mg) >60 500 40 to 60 250 20 to 40 125 <20 Contraindicated
Flecainide	I A	Oral: 200 to 300 mg Intravenous: 1.5 to 3.0 mg/kg over 10 to 20 min
Ibutilide	I A	1 mg over 10 min; repeat 1 mg when necessary
Propafenone	I A	Oral: 600 mg Intravenous: 1.5 to 2.0 mg/kg over 10 to 20 min
Amiodarone	IIa A	Oral: Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total then 200 to 400 mg per day maintenance or 30 mg/kg as single dose Outpatient: 600 to 800 mg per day divided dose until 10 g total then 200 to 400 mg per day maintenance. Intravenous: 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.

Cardioversion after 7 Days

Drug	Dosage
Dofetilide (I A)	Creatinine clearance(ml/min) Dose (mg) >60 500 40 to 60 250 20 to 40 125 <20 Contraindicated
Amiodarone (IIa A)	Oral: Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total then 200 to 400 mg per day maintenance or 30 mg/kg as single dose Outpatient: 600 to 800 mg per day divided dose until 10 g total then 200 to 400 mg per day maintenance. Intravenous: 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.
Ibutilide (IIa A)	1 mg over 10 min; repeat 1 mg when necessary

Drugs which enhance the efficacy of cardioversion when given prior to the procedure: (Level of recommendation: IIa B)

• Amiodarone
• Flecainide
• Ibutilide
• Propafenone
• Sotalol

Risk Factors for Stroke and Recommended Antithrombotic Therapy

Low Risk Factors	Moderate Risk Factors	High Risk Factors
Female gender	Age ≥ 75 years	Previous stroke, TIA or embolism
Age 65-74 years	Hypertension	Mitral stenosis
Coronary artery disease	Heart failure	Prosthetic heart valve
Thyrotoxicosis	LV ejection fraction ≤ 35%	-
-	Diabetes mellitus	-

Risk Category	Recommended Therapy
No risk factors	Aspirin, 81-325 mg daily
1 Moderate risk factor	Aspirin, 81-325 mg daily or Warfarin (INR 2.0 to 3.0, target 2.5)
Any high risk factor or more than 1 moderate risk factor	Warfarin (INR 2.0 to 3.0, target 2.5)*

Pharmacological Agents for Heart Rate Control

Drug	Class/LOE Recommendations	Loading Dose	Maintenance Dose
Acute Setting
Heart rate control in patients without accessory pathway
Esmolol	I C	500 mcg/kg IV over 1 min	60 to 200 mcg/kg/min IV
Propanolol	I C	0.15 mg/kg IV	NA
Metoprolol	I C	2.5 to 5 mg IV bolus over 2 min; up to 3 doses	NA
Diltiazem	I B	0.25 mg/kg IV over 2 min	5 to 15 mg/h IV
Verampil	I B	0.075 to 0.15 mg/kg IV over 2 min	NA
Heart Rate Control in patients with accessory pathway
Amiodarone	IIa C	150 mg over 10 min	0.5 to 1 mg/min IV
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin	I B	0.25 mg IV each 2 h, up to 1.5 mg	0.125 to 0.375 mg daily IV or orally
Amiodarone	IIa C	150 mg over 10 min	0.5 to 1 mg/min IV
Non-Acute Setting and Chronic Maintenance Therapy
Heart rate control
Metoprolol	I C	Same as maintenance dose	25 to 100 mg twice a day, orally
Propanolol	I C	Same as maintenance dose	80 to 240 mg daily in divided doses, orally
Verampil	I B	Same as maintenance dose	120 to 360 mg daily in divided doses; slow release available, orally
Diltiazem	I B	Same as maintenance dose	120 to 360 mg daily in divided doses; slow release available, orally
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin	I C	0.5 mg by mouth daily	0.125 to 0.375 mg daily, orally
Amiodarone	IIb C	800 mg daily for 1 wk, orally 600 mg daily for 1 wk, orally 400 mg daily for 4 to 6 wk, orally	200 mg daily, orally

• Dabigatran may be used as an alternative to warfarin in those wdo don't have: (I B)

• Prosthetic heart valve
• Hemodynamically significant valve disease
• Severe renal failure (creatinine clearance <15 mL/min) or
• Advanced liver disease (impaired baseline clotting function).

• If patient on anticoagulants with AF sustains stroke or systemic embolism, target INR may be raised to 3.0 - 3.5 (IIb C).
• Anticoagulation therapy can be interrupted for upto 1 week, if patients needs a procedure that carries a risk of bleeding (IIa C). For periods > 1 week unfractionated or low molecular weight heparin may be given IV (IIb C).