Key practice points
Early intervention is needed to reduce the health burden associated with atrial fibrillation (AF), however, this
should not expose the patient to unnecessary risk. Unless the onset of symptoms is definitely less than 12 hours,
electrical cardioversion should not be applied in haemodynamically stable patients without prior anticoagulation
due to the risk of thromboembolic complications. In most patients with newly diagnosed AF, treatment using
direct oral anticoagulants (DOACs) alongside rate control medicines is sufficient, and in many cases, AF will
spontaneously resolve without the need for intensifying management
- Oral anticoagulation alongside rate control – in addition to consistent follow-up – is the key to managing stable
patients with newly diagnosed AF
- DOACs are preferred over warfarin for stroke prevention
- Only select warfarin if patients have a creatinine clearance < 30 mL/min, a prosthetic heart valve or moderate
or severe mitral stenosis, a very high bleeding risk or if they are pregnant
- Dabigatran and rivaroxaban are both reasonable first choices with a similar clinical effect
- Use dabigatran if patients have multiple risk factors for bleeding (there is a lower risk of major bleeding compared
with rivaroxaban and a reversal agent is available)
- Use rivaroxaban if patients have adherence issues (once daily dosing), moderate renal dysfunction, or a history
of dyspepsia
- Aspirin or other antiplatelets are not recommended for long-term stroke prevention in patients with AF as they
are less effective than anticoagulatants
- Rate control strategies are preferred over rhythm control for managing AF symptoms
- Beta-blocker monotherapy is first-line, but further decisions should ideally be informed by an echocardiogram
- Target heart rate < 110 bpm
- Cardiologist input should guide the use of rhythm control strategies in patients with symptomatic AF not responding
to rate control; these include both pharmacological and electrical cardioversion, as well as more advanced procedures,
e.g. catheter or surgical ablation