Atrial fibrillation.
Stabilize the unstable (synchronized cardioversion), rate-control the stable, and find the trigger. Then prevent stroke by risk (CHA2DS2-VASc, DOAC over warfarin), choose rate vs early rhythm control and ablation, and cardiovert safely with the right anticoagulation window. Includes the WPW and decompensated-HF pitfalls and the 2024 ESC CHA2DS2-VA update.
Reviewed June 2026 · verify against current guidelines
Acute Management
Unstable? Cardiovert. Stable? Slow the rate.
Unstable means cardiovert now
- Hypotension, ischemic chest pain, pulmonary edema, or shock driven by the AF.
- Immediate synchronized cardioversion, starting at ≥200 J biphasic; sedate if time allows.
Stable RVR: rate control first
- Beta-blocker (IV metoprolol or esmolol) is the safe default for rate control.
- Reach for a non-DHP CCB (diltiazem) ONLY if the EF is known and preserved.
- Digoxin if hypotensive or in HFrEF; amiodarone if refractory or critically ill.
- Pre-excited AF (WPW, irregular wide-complex): avoid all AV-nodal blockers; cardiovert or procainamide.
Class 3 harm (2023 ACC/AHA): avoid IV diltiazem or verapamil with reduced EF or decompensated HF. Practical: if the EF is unknown, default to a beta-blocker.
RVR rapid ventricular responseCCB calcium channel blockerEF ejection fractionHFrEF heart failure with reduced EFWPW Wolff-Parkinson-WhiteAV atrioventricular
Diagnosis & Workup
Find the trigger. Name the pattern.
New AF is often secondary: treat the cause
- Sepsis, PE, hyperthyroidism, alcohol (holiday heart), low K or Mg, ischemia, hypoxia, post-op.
- Rate control plus correcting the trigger often restores sinus rhythm on its own.
Classify the pattern
| Paroxysmal | Stops within 7 days, often on its own. |
|---|---|
| Persistent | Sustained beyond 7 days; needs intervention to convert. |
| Long-standing | Continuous over 12 months. |
| Permanent | Rhythm control abandoned by shared decision. |
Valvular AF means a mechanical valve or moderate-to-severe mitral stenosis; it forces warfarin, not a DOAC.
PE pulmonary embolismMg magnesiumDOAC direct oral anticoagulant
Stroke Prevention
Anticoagulate by risk, not rhythm.
Score the stroke risk
- CHA2DS2-VASc: CHF, Hypertension, Age ≥75 (2), Diabetes, Stroke or TIA (2), Vascular disease, Age 65 to 74, Sex (female).
Who gets anticoagulation (2023 ACC/AHA)
| ≥2 male / ≥3 female | Annual risk ≥2%: anticoagulate (Class 1). |
|---|---|
| 1 male / 2 female | Risk 1 to 2%: anticoagulation is reasonable (Class 2a). |
| 0 male / 1 female | Low risk: no anticoagulation. |
Pick the agent
- A DOAC is preferred over warfarin (except mechanical valve or moderate-to-severe mitral stenosis).
- Consider LAAO if long-term anticoagulation is contraindicated. Aspirin does not prevent AF stroke.
2024 ESC uses CHA2DS2-VA (sex removed): anticoagulate at a score of 2 or more; female sex is a modifier, not a point.
TIA transient ischemic attackDOAC direct oral anticoagulantLAAO left atrial appendage occlusion
Acute Management
Rate or rhythm: and go early.
Rate control target
- Lenient resting heart rate under 110 is reasonable if asymptomatic with preserved EF (RACE II).
- Aim lower if symptoms persist. Beta-blocker or non-DHP CCB first-line; add digoxin or amiodarone.
Rhythm control pays off early
- Early rhythm control within ~1 year of diagnosis improves cardiovascular outcomes (EAST-AFNET 4).
- Catheter ablation is Class 1 first-line for symptomatic paroxysmal AF, and Class 1 in AF with HFrEF (reduces death and HF hospitalization).
- Antiarrhythmic choice depends on structural heart disease (flecainide or propafenone only if none).
Choose by symptoms, AF duration, age, and LV function. Rhythm control is most rewarding when started early.
EF ejection fractionHFrEF heart failure with reduced EF
Pitfalls & Disposition
Cardiovert safely. Treat the substrate.
Anticoagulation around cardioversion
| AF under 48 h, low risk | Cardiovert with periprocedural anticoagulation. |
|---|---|
| AF over 48 h or unknown | 3 weeks of therapeutic anticoagulation first, or a TEE to exclude left-atrial thrombus. |
| After every cardioversion | Anticoagulate at least 4 weeks; then long-term by CHA2DS2-VASc. |
Treat the substrate (lowers AF burden)
- Weight loss, treat sleep apnea, control blood pressure, cut alcohol, stay active.
Pitfalls: aspirin is not stroke prophylaxis; use bleeding risk (HAS-BLED) to modify, not withhold, anticoagulation; never skip the 4 weeks after cardioversion.
TEE transesophageal echocardiogramCHA<sub>2</sub>DS<sub>2</sub>-VASc AF stroke-risk scoreHAS-BLED anticoagulation bleeding-risk score
Sources
Verify against current guidelines and local protocol before acting.
- Joglar JE et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis & Management of Atrial Fibrillation. Circulation 2024;149(1):e1-e156.
- Van Gelder IC et al. 2024 ESC Guidelines for the management of atrial fibrillation (AF-CARE). Eur Heart J 2024;45(36):3314-3414.
- Van Gelder IC et al. Lenient versus strict rate control in AF (RACE II). N Engl J Med 2010;362:1363-73.
- Kirchhof P et al. Early rhythm-control therapy in AF (EAST-AFNET 4). N Engl J Med 2020;383:1305-16.
- Marrouche NF et al. Catheter ablation for AF with heart failure (CASTLE-AF). N Engl J Med 2018;378:417-27.
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