Diagnosis and Treatment of Atrial Fibrillation

 


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Am Fam Physician. 2016 Sep 15;94(6):442-452.

  Patient information: See related handout on atrial fibrillation.

Author disclosure: No relevant financial affiliations.

Atrial fibrillation is a supraventricular arrhythmia that adversely affects cardiac function and increases the risk of stroke. It is the most common arrhythmia and a major source of morbidity and mortality; its prevalence increases with age. Pulse rate is sensitive, but not specific, for diagnosis, and suspected atrial fibrillation should be confirmed with 12-lead electrocardiography. Because normal electrocardiographic findings do not rule out atrial fibrillation, home monitoring is recommended if there is clinical suspicion of arrhythmia despite normal test results. Treatment is based on decisions made regarding when to convert to normal sinus rhythm vs. when to treat with rate control, and, in either case, how to best reduce the risk of stroke. For most patients, rate control is preferred to rhythm control. Ablation therapy is used to destroy abnormal foci responsible for atrial fibrillation. Anticoagulation reduces the risk of stroke while increasing the risk of bleeding. The CHA2DS2-VASc scoring system assesses the risk of stroke, with a score of 2 or greater indicating a need for anticoagulation. The HAS-BLED score estimates the risk of bleeding. Scores of 3 or greater indicate high risk. Warfarin, dabigatran, factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban), and aspirin are options for stroke prevention. Selection of therapy should be individualized based on risks and potential benefits, cost, and patient preference. Left atrial appendage obliteration is an option for reducing stroke risk. Two implantable devices used to occlude the appendage, the Watchman and the Amplatzer Cardiac Plug, appear to be as effective as warfarin in preventing stroke, but they are invasive. Another percutaneous approach to occlusion, wherein the left atrium is closed off using the Lariat, is also available, but data on its long-term effectiveness and safety are still limited. Surgical treatments for atrial fibrillation are reserved for patients who are undergoing cardiac surgery for other reasons.

Atrial fibrillation is a supraventricular arrhythmia characterized by uncoordinated electrical activation of the atria and an irregular, often rapid, ventricular response causing hemodynamic compromise.1,2 As the atria fibrillate, blood pools in the atria, and a clot may form in the atrial appendage, increasing the risk of embolic stroke. Atrial fibrillation is associated with a fivefold increased risk of stroke,35 and it is the most common arrhythmia. It worsens heart failure and increases mortality in patients with myocardial infarction, and is an independent risk factor for death.68 The prevalence of atrial fibrillation increases with age, and the associated cost of medical care is high.9,10

WHAT IS NEW ON THIS TOPIC: ATRIAL FIBRILLATION

Ablation therapy may be superior to antiarrhythmics in selected patients, including those with paroxysmal atrial fibrillation who are symptomatic but without structural heart disease, patients who are intolerant of antiarrhythmics, and patients with inadequate pharmacologic rhythm control.

The CHA2DS2-VASc scoring system has replaced CHADS2 and is superior in estimating stroke risk.

Newer oral anticoagulants have a slightly lower risk of intracranial hemorrhage compared with warfarin (Coumadin), but dose adjustment is required in patients with renal disease.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

A beta blocker or nondihydropyridine calcium channel blocker should be used to control heart rate in atrial fibrillation.

B

1719

The target resting heart rate should be less than 80 beats per minute in symptomatic patients. More lenient control at less than 110 beats per minute is reasonable in asymptomatic patients with normal left ventricular function.

B

1820

Atrial ventricular nodal ablation is recommended for patients refractory to medical therapy, usually older patients needing a pacemaker.

C

1, 2, 22

The CHA2DS2-VASc score is recommended in the assessment of stroke risk.

C

2931

Anticoagulation options for patients with history of stroke/transient ischemic attack or a CHA2DS2-VASc score of 2 or greater include:

Warfarin (Coumadin; adjusted to international normalized ratio of 2 to 3)

A

3638, 40

Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa)

B

41, 4345

Aspirin is an option for patients with a CHA2DS2-VASc score of 0 or 1 and for patients who are unable to use other agents.

C

1, 2


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

A beta blocker or nondihydropyridine calcium channel blocker should be used to control heart rate in atrial fibrillation.

B

17

The Authors

show all author info

CECILIA GUTIERREZ, MD, is a clinical professor in the Department of Family Medicine and Public Health at the University of California, San Diego, School of Medicine....

DANIEL G. BLANCHARD, MD, is a professor of medicine in the Division of Cardiovascular Medicine at the University of California, San Diego, School of Medicine.

Address correspondence to Cecilia Gutierrez, MD, University of California, San Diego, 9500 Gilman Dr., Mail Code 0807, San Diego, CA 92093. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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