This document summarizes the management of atrial fibrillation. It outlines that the main approaches are rate control, anticoagulation, and rhythm control. A key decision is determining a patient's stroke risk using the CHA2DS2-Vasc score to guide appropriate anticoagulation. For acute atrial fibrillation under 48 hours, the priorities are hemodynamic stability, rate control with medications, and anticoagulation if cardioversion is planned. For chronic atrial fibrillation, long-term anticoagulation and rate control are emphasized along with considering rhythm control if symptomatic.

1. MANGMENT OF ATRIAL
FIBRILLATION
Done by: Elias Zurigat
eliaszaitoun@gmail.com

2. • The cornerstones of atrial fibrillation (AF)
management are rate control and
anticoagulation and rhythm control.
• One of the major management decisions in
(AFib) is determining the risk of stroke and
appropriate anticoagulation regimen for low-,
intermediate-, and high-risk patients.

4. CHA2DS2-Vasc score

5. Management for acute Afib <48h
• If patient is haemodynamically unstable:
admision and emergency electrical
cardioversion; if unavailable IV amiodarone.
• If patient is haemodynamically stable:
- Control rate 1st line: Ca channel blocker;
verapamil (40-120mg/8h), or beta blocker;
bisoprolol (2.5-5.0mg/d).
- 2nd line: digoxin and amiodarone.

6. • Anti-coagulation:
-Patients waiting electrical cardioversion can be
started on intravenous heparin or (LMWH),if
<48 hours.
- >48 hours, ensure >3 weeks of theraputic
anticoagulation before elective cardioversion. (
trans-oesophageal echo)
-Patients can be started concomitantly on
warfarin in an inpatient setting while
monitring [INR] value (2-3), if high risk of
thrombo embolic event.

7. Management of chronic AFib
• Anticoagulation:
-warfarin and aim for an INR= 2-3.
- except in patients who are at a high risk for stroke,
in whom the INR should be maintained between 2.5
and 3.5.
- Less good alternative is aspirin 300mg/d, if warfarin
is CI, or at very low risk of emboli.
- Dabigatran; direct thrombin inhibitor. Despite it`s
expense, it doesn`t require lab monitoring and dose
adjustment.

8. • Rate control: 1st line is beta blockers and Calcium
blockers. If this fails, add digoxin, then cosider
amiodarone.
• Rhythm control: if symptomatic, CCF, presenting
for the 1st time with lone AFib, AFib from a
corrected precipitant.
-Do echo 1st, pre-treat for >=4weeks with sotalol or
amiodarone( previous faliure of cardioversion,
recurrance)
- Flecainiade is 1st choice, if no structural heart
disease. Otherwise give IV amiodarone.
- Av node ablation

9. • Paroxysmal Afib ‘PILL IN THE POCKET’ sotalol
or flecainide.
• Anticoagulate as above.

10. Outpatient care
• Assessment and reassessment of
thromboembolic risk is necessary.
• ECG monitoring (especially when taking
antiarrhythmic agents) and Holter monitoring.

11. THANK YOU…