Therapy

Acute-onset atrial fibrillation

Control the ventricular rate using ^d digoxin  ^a  

Alternatives include

• calcium channel blockers: verapamil ^a or diltiazem ^a
• beta blockers: esmolol ^a  or sotalol ^a  
• clonidine ^b  

Options include

• DC cardioversion ^a. 
  Cardioversion is more likely to be successful if  ^a  
  
  • the onset of this episode of arrythmia is recent 
  • your patient is young 
    
  Anticoagulate your patient before and after cardioversion ^c  

  Consider 

  • using transoesophageal echocardiography to determine when to perform the cardioversion  ^a
  • giving an initial shock of 360 J if AF duration > 48 hours ^a
  • internal cardioversion ^a  
  • giving an infusion of ibutilide before cardioversion ^a  
  
  There is no clear benefit from
  • using propafenone before DC cardioversion ^d  
  • different pad ^d or electrode positions ^d  

   

• pharmacological cardioversion
  • flecainide iv or oral   ^a  
  • ibutilide ^a  
  • procainamide ^a  
  • propafenone ^a  
  • amiodarone iv or oral ^a  
  • quinidine and verapamil ^a

Chronic atrial fibrillation

• calcium-channel blockers ^a: verapamil ^a or diltiazem  ^a
• beta-blockers ^a: esmolol ^a  or sotalol ^a
• digoxin ^a preferably in combination with a calcium-channel blocker or beta-blocker
• clonidine ^b  

• See acute AF section for more details.

Cardioversion is less likely to be successful in the long term if patients 

• have had AF for more than 3 months ^a  
• have severe heart failure ^a  
• are old ^a  

and more likely if they have non-rheumatic mitral valve disease  ^a  

Alternatives to amiodarone include 

• flecainide ^b  
• disopyramide ^a  

  There is no clear benefit from adding ^a

  • propafenone
  • quinidine
  • sotalol

   

• ibutilide or oral dofetilide ^a  
• flecainide ^a
• amiodarone ^a  
• propafenone ^a  
• quinidine ^a

• disopyramide
• magnesium
• digoxin
• sotalol ^d

For patients with symptomatic chronic AF resistant to medication, consider

• radiofrequency AV node modulation ^c  
• atriotomy ^c