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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

Consider antiarrythmic therapy for maintenance of sinus rhythm

Attempt cardioversion Click here for drugs and doses used for pharmacological cardioversion If patient hemodynamically unstable or tachycardic attempt electric cardioversion If pharmacological cardioversion fails attempt electric cardioversion

Do not treat with long term antiarrythmic therapy, unless indicated.

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.

• 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).