• The first priority is to control heart rate (if tachycardia is present) and provide adequate antithrombotic treatment for preventing complications of embolism
  • Patients with moderate to high risk of stroke require warfarin long term for preventing emboli; aspirin is adequate in patients with low risk of stroke
  • When a patient should but cannot take warfarin, aspirin plus clopidogrel can be an intermediate option
  • For long term treatment of atrial fibrillation, rate control matches rhythm control in terms of mortality and major cardiovascular events but has fewer adverse events related to the treatment and fewer hospital admissions
  • Consider referring for rhythm control younger patients with lone atrial fibrillation, patients with symptomatic atrial fibrillation, and patients with atrial fibrillation secondary to a corrected precipitant
  • If antiarrhythmic drugs fail to maintain sinus rhythm, percutaneous catheter ablation is an alternative for rhythm control

If patient stable and on warfarin - do not interfere.

  • If atrial fibrillation present for more than one year, cardioversion usually not done.
  • If atrial fibrillation present for less than one year, consider cardioversion.
  • If atrial fibrillation uncontrolled, use digoxin.
  • What is cause of atrial fibrillation?
    • ECG
    • CXR
    • TFT (U&E, FBC, LFT)
    • Echocardiography determines whether patient should be commenced on aspirin or warfarin.
Treatment
  • Patients with tachycardia plus syncope, chest pain, dyspnoea, or acute neurological symptoms should be sent immediately to hospital for urgent treatment
  • Use β blockers, diltiazem, or digoxin (if heart failure is present), or a combination of these drugs at standard doses to slow heart rate in atrial fibrillation if tachycardia is present

Anticoagulaton  and risk

Risk factors - so more suitable for warfarin:

  • Age > 65
  • Hypertension
  • LV dysfunction or failure
  • Previous thromboembolism
  • Diabetes
  • Coronary artery disease

CHADS2 risk assessment score

HAS-BLED score for major bleeding risk

  BHF factfiles

NICE CG36

CKS on AF

NICE atrial fibrillation guidelines

10-Minute Consultation: atrial fibrillation

Atrial fibrillation emergency resuscitation

Management of atrial fibrillation BMJ 2009


Starting digoxin

Loading dose

15mcg per kg of estimated lean body weight, given in 3 divided doses at 6 hour intervals

eg: 50kg woman requires 750mcg = 250mcg x3 doses 6 hours apart.

If ventricular rate not slowed and no signs of toxicity, try another 5mcg per kg

Maintenance

Creatinine clearance (ml/min) Daily maintenance dose as a fraction of effective loading dose
100 1/3
50 1/4
25 1/5
10 1/6
0 1/7

Reference: BHF factfile 7/2001