Long-term management of AF

All patients should have their heart rate controlled to less than 110bpm at rest AND be asymptomatic of the AF.

This can be done either by “Rate” or “Rhythm” control, or sometimes a combination of both.

They both have advantages as well as disadvantages. As a result, the decision is made on an individual basis which is influenced by

• The patient’s symptoms
• Pre-existing cardiac disease/ other co-morbidities that predispose you to AF
• Length of time in AF (if the patient has no symptoms, this can be “guestimated” by the size of the left atrium. So if it is enlarged, they are more likely to have been in AF for a while).
• Size of LA: the more enlarged it is, the more likely someone is to stay in AF
• Medication options: based on lifestyle, potential side effects and other medical problems.

Rhythm Management:

This is when we try to return the patient from AF to sinus rhythm. This can be done either via DC cardio version or by using medications.

The most common medications used are: amiodarone, flecainide, dronedarone.

For patients who have symptomatic paroxysmal AF, are sometimes managed by a system called” Pill in the pocket”. This means that they take their rhythm control medication only when they are aware of the AF occurring, rather than taking it on a daily basis.

The British Heart Foundation have useful information about DC cardioversion.

Rate Management

This is the preferred choice for patients with longstanding AF and who have conditions that predispose them to AF. Rate control medications are probably safer than rhythm control medications.

The most common rate control drugs are: beta-blocker, rate-limiting-calcium-channel blocker, digoxin.

For patients who are aware of their AF (dyspnoea, fatigue, syncope and dizziness) it may be necessary to be a little more aggressive with the rate control (aim for a rate control of <80-bpm). People who have coronary heart disease may also require more aggressive heart rate control.

Page last reviewed: 29 Jul 2020